









■ ■ 



■ 
KB 




SaM*" 



— / 



LIBRARY OF CONGRESS, 

■fop. Co|ii;ri$i fy. 

Shelf 

IMTED STATES OF AMERICA. 



PRACTICAL TREATISE 



FRACTURES AND DISLOCATIONS. 



S 



BY 



FRANK HASTINGS HAMILTON, A.B., A.M., M.D., LL.D., 

LATE PROFESSOR OF SURGERY IN BELLEVUE HOSPITAL MEDICAL COLLEGE, AND SURGEON TO 

BELLETUE HOSPITAL, NEW YORK: CONSULTING SURGEON TO HOSPITAL FOR RUPTURED 

AND CRIPPLES, TO ST. ELIZABETH HOSPITAL, ETC. J AUTHOR OF A TREATISE 

ON MILITARY SURGERY AND HYGIENE, A TREATISE ON THE 

PRINCIPLES AND PRACTICE OF SURGERY, ETC.] 



SEVENTH AMERICAN EDITION, REVISED AND IMPROVED. 



ILLUSTRATED WITH THREE HUNDRED AND SEVENTY-NINE WOOD-CUTS. 




PHILADELPHIA: 

HENRY C. LEA'S SON & CO. 

1884. 



v 






Entered according to the Act of Congress, in the year 1884, by 

EENRY C. LEA'S SON & CO., 
in the Office of the Librarian of Congress. All rights reserved. 



DORNAN, PRINTER. 



K 



PREFACE TO THE SEVENTH AMERICAN EDITION. 



In preparing this edition for the press, the Author has made a 
careful study of the most recent contributions to the literature of 
fractures and dislocations as found in the various American and 
foreign medical journals, and in the latest surgical treatises; 
including the excellent treatise on fractures lately published by 
his distinguished friend, Dr. Lewis A. Stimson, of New York : 
but for most of the additional matter contained in the present 
edition he must acknowledge his indebtedness to Dr. A. Poin- 
sot, Professor Agrege of Medicine of Bordeaux, and Surgeon to 
the Hospital, who, as translator and editor of the French edition 
of this treatise published in 18S4 by Bailliere & Sons, of Paris, 
has brought together a large number of more lately recorded 
facts and observations relating to this subject, and has added 
valuable suggestions of his own. These contributions the 
Author has utilized in the present edition, and has added many 
observations drawn from his own more recent personal experi- 
ence. The result has been a considerable enlargement of the 
size of the volume, and, as he trusts the reader will find, a 
proportionate increase in its practical value. 

Some apology or explanation may be due to many of the 
writers on these subjects who have been occupied, especially of 
late, in experiments upon the cadaver, for the purpose of deter- 
mining the nature, causes, mechanism, and treatment of fractures 
in the vicinity of joints, and of dislocations, in that he has not, 
generally, attached to them the same degree of importance 
which the experimenters seem to have claimed for them. 

There can be no doubt that most of these experiments famish 



VI PREFACE TO THE SEVENTH AMERICAN EDITION. 

valuable information, which it would be unwise to reject; but it 
is equally beyond doubt that the results thus obtained cannot be 
accepted as illustrating precisely what usually occurs in trau- 
matisms inflicted upon the living body, while the muscles retain 
their normal activity. In the case of fractures, the rigidity of the 
muscles is always a factor of great importance in determining the 
seat and character of the lesion, and in some cases it is the sole 
factor. In the case of dislocations the same is true, only in a 
much greater degree. A large proportion of traumatic disloca- 
tions are determined in their nature, direction, and extent by the 
violent, and often spasmodic, action of the muscles acting in 
connection with the direction and force of the external violence. 
Some are dependent solely upon the action of the muscles. It is 
also the sole determining cause in all idiopathic, spontaneous, or 
pathological dislocations. In neither fractures nor dislocations 
made upon the cadaver can this action be imitated or supple- 
mented. 

On the other hand, clinical observations alone cannot always 
be relied upon to settle a disputed point in the mechanism and 
nature of a traumatism belonging to the classes of which we are 
speaking, and especially when the question relates to a lesion 
involving a joint; and this partly because of the difficulty of 
making a diagnosis while the seat of lesion is covered with soft 
and sensitive tissues, partly because of the fallibility of the testi- 
mony furnished by the patients themselves, and partly because 
of the fact that the reliability of the surgeon as an expert who 
has reported the case is not always established, and the report 
has not, therefore, any more value than common "hearsay." 

Finally, nothing is more unreliable than the testimony furn- 
ished by cabinet specimens whose clinical history is wholly un- 
known ; and in reference to which, in many cases, it is impossible 
to say whether their present condition was due to traumatism 
before or after death, or, indeed, whether it was not due to some 
long preexisting pathological cause. The fact that by different 
students these specimens are often interpreted differently, is suf- 



PREFACE TO THE SEVENTH AMERICAN EDITION. Vll 

ficient to justify the statement we have made as to their occa- 
sional worthlessness as testimony. 

From the beginning of his studies, the Author has found one 
of his most difficult labors in attempting to eliminate from the 
branch of science which he has undertaken to teach, the numerous 
"false facts,'* or unreliable statements derived from these several 
sources; and this must be accepted as his apology for his re- 
peated expressions of scepticism in reference to testimony, some 
of which has been accepted, as is believed without sufficient 
examination, by writers whose opinions might be regarded as of 
more value than his own. 

The Author wishes to express his obligations to Dr. Lucien 
Damainville, for much valuable assistance rendered in the pre- 
paration of this edition. 

FRANK H. HAMILTON. 

43 W. 32d Street. New York. 
May 1. 1884. 



PREFACE TO THE FIRST EDITION. 






The English language does not at this moment contain a single 
complete treatise on Fractures and Dislocations. The two small 
volumes of Desault, and the one of Boyer, issued near the close 
of the last century, and translated into English early in this, 
may perhaps properly enough have been regarded as complete 
treatises at the time of their publication, but they certainly 
cannot be so considered now. The several chapters on "Diseases 
and Injuries of the Bones," contained in the Lemons Orales of 
Dupuytren, translated in 1846, and the Treatise on Fractures in the 
Vicinity of the Joints, and on Certain Forms of Accidental and Con- 
genital Dislocations, by Robert Smith, are invaluable monographs, 
but neither of them claims to be anything more than a collection 
of occasional and miscellaneous papers. The writings of Ames- 
bury and of Lonsdale relate only to fractures. Even the justly 
celebrated quarto of Sir Astley Cooper is no more than what its 
title plainly declares it to be, A Treatise on Dislocations and on 
Fractures of the Joints; but since the announcement of the present 
volume, a translation of Malgaigne's great and crowning work 
on Fractures and Dislocations has been commenced by Dr. Pack- 
ard, of Philadelphia, and the first volume has been placed in the 
hands of the American profession. Should the remaining volume 
be rendered into English, the gap in our literature will be meas- 
urably filled. 

Under these circumstances I might scarcely have thought it 
worth while to continue my labors, already so near their com- 
pletion, had it not seemed to me that Malgaigne, whose researches 
have been truly marvellous, had failed in some measure to give a 



X PREFACE TO THE FIRST EDITION. 

just representation of the observations and improvements which 
have been made from time to time by my own countrymen. 

The contributions of American surgeons to this department 
had to be sought chiefly in medical journals, many of which have 
long been discontinued, and most of which were inaccessible to 
the great French writer. Even to an American, the labor of 
exhumation from archives hitherto almost unexplored has not 
been small ; and it is probable that many valuable papers have 
been overlooked ; indeed it is impossible that it should be other- 
wise. 

I am free to say, also, that I have been encouraged by a hope 
that my own personal experience, obtained during many years 
of public and private service, might be of some value to my con- 
temporaries. 

Very little space has been devoted to what is now only 
historical, except so far as was necessary to correct certain time- 
consecrated errors, or to confirm and illustrate the practice of 
the present day; but by a pretty full report of characteristic 
examples, selected from more than one thousand cases already 
published by myself, by copious references to the examples 
recorded by others, and by a careful exclusion of whatever has 
not been confirmed by experience or established by dissection, I 
have endeavored to make this treatise useful both to the student 
and practical man, and a reliable exponent of the present state 
of our art upon those subjects of which it treats. 

In order to render the description of the various forms of appa- 
ratus employed in the treatment of fractures more intelligible, 
and to avoid the necessity of lengthened explanations, a large 
number of illustrations have been introduced, more, perhaps, 
than might be thought necessary, especially as in several in- 
stances the apparel which is figured is not that which is recom- 
mended by the author. It is believed, however, that by a study 
of the principal forms of approved dressings the reader will be 
better prepared for the exigencies of practice ; and that by the 
simultaneous presentation of those which are not approved, he 
will be saved from a wasteful expenditure of his time in the con- 






PREFACE TO THE FIRST EDITION. XI 

(advance of useless apparatus. It is not in the discovery and 
multiplication of mechanical expedients that the surgeon of this 
day declares his superiority, so much as in the skilful and judi- 
cious employment of those which are already invented. 

The author desires to acknowledge his indebtedness to very 
many of his professional brethren, throughout the United States, 
for the promptness with which they have responded from time to 
time to his inquiries, and for the generosity with which they have 
opened their pathological collections and placed valuable speci- 
mens at his disposal. 

He wishes also to express his special obligations to Dr. J. R. 
Lothrop, of this city, who has kindly aided him in revising most 
of the proof-sheets as they have been issued from the press. 

FRANK H. HAMILTON. 
Buffalo, N. Y., December. 1859. 



CONTENTS. 



PART I. 

FRACTURES. 

CHAPTEK I. 

PAGE 

General Division of Fractures 35 

CHAPTER II. 
General Etiology of Fractures 37 

CHAPTER III. 
General Semeiology and Diagnosis of Fractures .... 42 

CHAPTER IV. 
Repair of Fractures 46 

CHAPTER V. 
General Prognosis of Fractures 52 

CHAPTER VI. 

General Treatment of Fractures 61 

CHAPTER VII. 
Delayed Union. Fibrous Union, and Non-union of Fractures . 84 

CHAPTER VIII. 

BrarDoro, Partial Fractures, and Fissures of the Long Bones . . 96 

\ 1. Bending of the Long Bones 96 

\ •_'. Partial Fractures of the Long Bones 99 

\ ■',. Figures 108 

(II APT Kit IX. 

Fractures of the Xose L18 

\ 1. Fractures of the Os.^a Nasi 113 

', 2. Fractures and Displacement- <>i' the Septum Xarium . . . 118 



XIV 



CONTENTS. 



CHAPTER X. 
Fractures of the Malar Bone . 



PAGE 

121 



CHAPTER XL 

Fractures of the Upper Maxillary Bones 



124 



CHAPTER XII. 

Fractures of the Zygomatic Arch . 

CHAPTER XIII. 
Fractures of the Lower Jaw .... 



CHAPTER XIV. 
Fractures of the Hyoid Bone . 



130 



133 



160 



CHAPTER XV. 

Fractures of the Cartilages of the Larynx 165 

§ 1. Fractures of the Thyroid Cartilage 165 

\ 2. Fractures of the Thyroid and Cricoid Cartilages . . . .167 
\ 3. Fractures of the Cricoid Cartilage . . . . . . .168 



CHAPTER XVI. 

Fractures of the Vertebrae .... 
§ 1. Fractures of the Spinous Processes . 
\ 2. Fractures of the Transverse Process . 
§ 3. Fractures of the Vertebral Arches 
\ 4. Fractures of the Bodies of the Vertebra? . 

1. Fractures of the Bodies of the Lumbar Vertebra? 

2. Fractures of the Bodies of the Dorsal Vertebra? 

3. Fractures of the Bodies of the five lower Cervical Vertebra? 

4. Treatment of Fractures of the Bodies of the Vertebra? . 

\ 5. Fractures of the Axis 

| 6. Fractures of the Atlas 

\ 7. Fractures of the first two Cervical Vertebra? (Atlas and Axis) at the 
same time ........... 



CHAPTER XVII. 



Fractures of the Sternum . 



171 
171 
173 
174 
179 
181 
183 
184 
187 
190 
193 

194 



195 



CHAPTER XVIII. 

Fractures of the Ribs and their Cartilages 202 

I 1. Fractures of the Ribs 202 

\ 2, Fractures of the Cartilages of the Ribs 208 

CHAPTER XIX. 

Fractures of the Clavicle 209 



CONTENTS. 



CHAPTER XX. 

Fractures or the Scapula . . . 

| 1. Fractures of the Body of the Scapula 
I 2. Fractures of the Neck of the Scapula 
§ 3. Fractures of the Acromion Process . 
\ 4. Fractures of the Coracoid Process 



PAGE 

237 
237 
242 
243 
247 



CHAPTER XXI. 

Fractures of the Humerus 250 

\ 1. Fractures of the Head and Anatomical Neck 251 

\ 2. Fractures through the Tubercles 256 

\ 3. Longitudinal Fractures of the Head and Neck, or Splitting off of 

the Greater Tubercle 257 

\ 4. Fractures through the Surgical Neck (including Separations at the 

Upper Epiphysis) 259 

\ 5. Fractures of the Shaft below the Surgical Neck, and above the Base 

of the Condyles .......... 277 

\ 6. Fractures at the Base of the Condyles (including Separations of the 

Lower Epiphysis) 289 

I 7. Fracture at the Base of the Condyles, complicated with Fracture 

between the Condyles, extending into the Joint .... 298 

I 8. Fractures of the Internal Epicondyle 302 

g 9. Fracture or Diastasis of the External Epicondyle .... 309 

\ 10. Fractures of the Internal Condyle ....... 310 

\ 11. Fractures of the External Condyle 313 

| 12. Fractures of the Articular Processes of the Humerus (wholly within 

the Capsule) 317 



CHAPTER XXII. 



Fractures of the Radius 



318 



CHAPTER XXIII. 



Fractures of the Ulna 

\ 1. Fractures of the Olecranon Process 
$ 2. Fractures of the Coronoid Process 
I 3. Fractures of the Shaft 
\ 4. Fractures of the Styloid Process 



356 
356 
365 
375 



CHAPTER XXIV. 

FRA« TURKS OF THE RADIUS AND ULNA 



380 



CHAPTER XXV. 
Fractures of the Carpal Bones 



CHAPTER XXVI. 
Fractures of the Metacarpal Bonks 



. 392 



CONTENTS. 



CHAPTER XXVII. 



Fb \< [■[ ass of in k Fingers 



PAGE 

395 



CHAPTER XXVIII. 

Fractures of the Pelvis, and Traumatic Separations at its Sym- 
physes 399 

g 1. Fractures of the Pubes 399 

(a) Separations at the Symphysis Pubis ..... 399 

(b) True Fractures of the Pubes 401 

I 2. Fractures of the Ischium 403 

g 3. Fractures of the Ilium . . 404 

\ 4. Fractures of the Acetabulum 407 

(a) Fractures of the Base 408 

(b) Fractures of the Rim 411 

\ 5. Fractures of the Sacrum . . 415 

'i 6. Fractures of the Coccyx 410 



Fractu 
§ 1 



\ 2. 



«4. 

\ 6. 



CHAPTER XXIX. 

res of the Femur 418 

Fractures of the Neck of the Femur 419 

(a) Neck of the Femur within the Capsule 420 

(6) Neck of the Femur without the Capsule .... 445 
(c) Neck of the Femur partly within and partly without the Cap- 
sule 453 

Fractures through the Trochanter Major and Base of the Neck of 

the Femur 454 

Fractures of the Epiphysis of the Trochanter Major . . . 456 

Fractures of the Shaft of the Femur 458 

Fractures at or near the Base of the Condyle ..... 515 

Fractures of the Condyles 523 

(a) Fractures of the External Condyle 523 

(b) Fractures of the Internal Condyle 525 

(c) Fractures between the Condyles and across the Base . . 527 

(d) Separation of the Lower Epiphysis 528 

Non-union and Delayed Union of Fractures of Shaft of Femur . 530 



CHAPTER XXX. 



Fractures of the Patella . 



534 



Fractures of the Tibia 



CHAPTER XXXI. 



566 



CHAPTER XXXII. 



Fractures of the Fibula 



572 



CHAPTER XXXIII. 
Fractures of the Tiiua and Fibula . 



580 



CONTENTS. ' XV11 

CHAPTER XXXIV. 

PAGE 

Fractures of the Tarsal Bones 604 

CHAPTER XXXV. 
Fractures of the Metatarsal Bones 611 

CHAPTER XXXVI. 
Fractures of the Phalanges of the Toes 612 

CHAPTER XXXVII. 
Gunshot Fractures 613 



PART II. 

DISLOCATIONS. 

CHAPTER I. 

General Considerations 629 

g 1. Division and Nomenclature 629 

\ 2. Predisposing Causes 630 

\ 3. Direct or Exciting Causes 631 

\ 4 Symptoms 632 

Pathology 633 

Prognosis 634 

$ 7. Treatment 634 



CHAPTER II. 

Dislocations of the Lower Jaw 

\ 1. Double or Bilateral Dislocations 
8 ingle or Unilateral Dislocations 
\ ■',. Dislocations Outwards, with Fracture 
I 4. Dislocations Backwards, with Fracture 
\ ■>. Conditions of the Jaw simulating Dislocation 



637 
638 
642 
643 
643 
645 



CHAPTER III. 
Dislocations oi the Hyoid Bone 646 



CONTENTS. 



CHAPTER IV. 

PAGE 

Dislocations of the Spine 647 

# 1. Dislocations of the Lumbar Vertebra? 648 

§ 2. Dislocations of the Dorsal Vertebra? 650 

g 3. Dislocations of the Six Lower Cervical Vertebra? .... 652 

g 4. Dislocations of the Atlas 660 

$ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean Dis- 
locations 663 

CHAPTER V. 

Dislocations of the Ribs 663 

g 1. Dislocations of the Ribs from the Vertebra? 664 

g 2. Dislocations of the Ribs from the Sternum 665 

§ 3. Dislocations of one Cartilage upon Another ..... 666 

CHAPTER VI. 

Dislocations of the Clavicle 667 

I 1. Sterno-Clavicular 667 

(a) Dislocations of the oternal End of the Clavicle Forwards . 667 

(b) Dislocations of the Sternal End of the Clavicle Upwards . 671 

(c) Dislocations of the Sternal End of the Clavicle Backwards . 673 
$ 2. Acromio-Clavicular .......... 675 

(a) Dislocations of the Acromial End of the Clavicle Upwards . 675 

(b) Dislocations of the Acromial End of the Clavicle Downwards 681 

(c) Dislocations of the Acromial End of the Clavicle under the 

Coracoid Process 683 

(d) Dislocations of the Clavicle at both ends, simultaneously . 684 

CHAPTER VII. 

Dislocations of the Shoulder (Scapulo-Humeral) .... 685 

\ 1. Dislocations of the Shoulder Downwards (Subglenoid) . . . 686 
Dislocations, with Fracture of the Humerus near its Upper End . 718 
§ 2. Dislocations of the Humerus Forwards (Subcoracoid and Subcla- 
vicular) ............ 719 

$ 3. Dislocations of the Humerus Backwards (Subspinous) . . . 728 

\ 4. Dislocations of the Humerus Upwards 734 

\ 5. Partial Dislocations of the Humerus 738 

CHAPTER VIII. 

Dislocations of the Head of the Radius (Humero-Radial) . . . 743 

\ 1. Dislocations of the Head of the Radius Forwards .... 743 

g 2. Dislocations of the Head of the Radius Backwards .... 749 

\ 3. Dislocations of the Head of the Radius Outwards .... 751 

CHAPTER IX. 

Dislocations of the Upper End of the Ulna (Humero-Ulnar) . . 752 

$ 1. Dislocations of the Upper End of the Ulna Backwards . . . 752 

\ 2. Dislocations of the Upper End of the Ulna Inwards . . . 753 



CONTEXTS. XIX 
CHAPTER X. 

PAGE 

Dislocations of the Radius and Ulna (Forearm) at the Elbow-Joint 754 

| 1. Dislocations of the Radius and Ulna Backwards .... 754 

§ 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side) . 765 

(a) Complete Outward Dislocations ...... 765 

(b) Incomplete Outward Dislocations ...... 768 

§ 3. Dislocations of the Radius and Ulna Inwards (to the Ulnar Side) . 772 

§ 4. Dislocations of the Radius and Ulna Forwards 775 

| 5. Diverging Dislocations of the Radius and Ulna .... 777 

(a) Dislocations of the Radius Forwards, and Ulna Backwards . 777 

(b) Transverse, Ulna Inwards, and Radius Outwards . . . 778 

(c) Oblique, Ulna Backwards, and Radius Outwards . . . 778 

(d) Oblique, Ulna Forwards, and Radius Outwards . . . 779 

CHAPTER XI. 

Dislocations of the Wrist (Radio-Carpal) 779 

§ 1. Dislocations of the Carpal Bones Backwards 782 

\ 2. Dislocations of the Carpal Bones Forwards 785 

CHAPTER XII. 

Dislocations of the Lower End of the Ulna (Inferior Radio-Ulnar) 786 

\ 1. Dislocations of the Lower End of the Ulna Backwards . . . 786 

g 2. Dislocations of the Lower End of the Ulna Forwards . . . 787 

CHAPTER XIII. 

Dislocations of the Carpal Bones (among themselves) . . . 789 

CHAPTER XIV. 

Dislocations of the Metacarpal Bones (at the Carpo-Metacarpal 

Articulations) 791 

\ 1. Dislocations of the Metacarpal Bone of the Thumb Backwards . 791 

\ 2. Dislocations of the Metacarpal Bone of the Thumb Forwards . . 793 

g 3. Dislocations of the Metacarpal Bone of the Fingers .... 794 

CHAPTER XV. 

Dislocations of the First Phalanges of the Thumb and Fingers 

(Metacarpophalangeal) 795 

\ 1. Dislocations of the First Phalanx of the Thumb Backwards . . 795 

g 2. Dislocations of the First Phalanx of the Thumb Forwards . . 908 

g 3. Dislocations of the First Phalanx of the Fingers .... 804 

CHAPTER XVI. 

Dislocations o» tele Second and Third Phalakoss of the Thumb and 

Fingers (Phalanoka li 506 



CONTENTS. 



CHAPTER XVII. 



Dislocations of the Thigh (Coxo-Femoral) 808 

g 1. Dislocations Upwards and Backwards on the Dorsum Ilii . . 810 

§ 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch 841 
g 3. Dislocations Downwards and Forwards into the Foramen Thy- 

roideum 849 

§ 4. Dislocations Upwards and Forwards upon the Pubes . . . 857 
\ 5. Anomalous Dislocations, or Dislocations which do not properly belong 

to either of the four principal divisions before described . 863 

1. Dislocations directly Upwards above the Margin of the Ace- 

tabulum, and Below the Anterior Inferior Spinous Process . 863 

2. Dislocations directly Upwards, between the Anterior Inferior 

and Anterior Superior Spinous Processes .... 866 

3. Dislocations Upwards upon the Dorsum Ilii, and near its 

Anterior Margin 867 

4. Dislocations Downwards and Backwards upon the Posterior 

Part of the Body of the Ischium, between its Tuberosity 

and its Spine 868 

5. Dislocations Downwards and Backwards into the Lesser or 

Lower Ischiatic Notch . . . . . . . . 869 

6. Dislocations directly Downwards 870 

7. Dislocations Forwards into the Perineum .... 870 
\ 6. Ancient Dislocations of the Femur ....... 872 

§ 7. Partial Dislocations of the Femur 880 

\ 8. Coxo-Femorai Dislocations, complicated with Fracture of the Femur 881 

§ 9. Voluntary or Spontaneous Dislocations of the Femur . . . 884 



CHAPTER XVIII. 



Dislocations of the Patella 

| 1. Dislocations of the Patella Outwards 
§ 2. Dislocations of the Patella Inwards . 
§ 3. Dislocations of the Patella upon its Axis 

(a) Vertical ... 

(b) Complete Version . 

§ 4. Dislocations of the Patella Upwards . 



896 
897 
897 
901 
902 



CHAPTER XIX. 

Dislocations of the Head of the Tibia (Femoro-Tibial) 
\ 1. Dislocations of the Head of the Tibia Backwards 
\ 2. Dislocations of the Head of the Tibia Forwards 
\ 3. Dislocations of the Head of the Tibia Outwards 
3 4. Dislocations of the Head of the Tibia Inwards . 
\ 5. Dislocations of the Head of the Tibia Backwards and Outwards 
\ 6. Dislocations of the Head of the Tibia Forwards and Outwards 
g 7. Dislocations of the Head of the Tibia Forwards and Inwards 
\ 8. Dislocations of the Head of the Tibia by Rotation 
g 9. Internal Derangement of the Knee-joint .... 



904 
904 
906 
909 
910 
911 
912 
912 
913 
913 



CONTENTS. 



CHAPTER XX. 

Dislocations of the Lower End of the Tibia (Tibio-Tarsal) 
§ 1. Dislocations of the Lower End of the Tibia Inwards 
| 2. Dislocations of the Lower End of the Tibia Outwards 
I 3. Dislocations of the Lower End of the Tibia Forwards 
§ 4. Dislocations of the Lower End of the Tibia Backwards 



PAGE 

916 
916 
921 
922 
926 



CHAPTER XXI. 

Dislocations of the Upper End of the Fibula 

§ 1. Dislocations of the Upper End of the Fibula Forwards 
\ 2. Dislocations of the Upper End of the Fibula Backwards 



927 

927 
928 



CHAPTER XXII. 

Dislocations of the Lower End of the Fibula 



930 



CHAPTER XXIII. 



Tarsal Dislocations 

\ 1. Dislocations of the Astragalus . 

\ 2. Astragalo-Calcaneo-Scaphoid Dislocations 

I 3. Dislocations of the Calcaneum . 

| 4. Middle Tarsal Dislocations 

Dislocations of the Cuboid Bone 
\ 6. Dislocations of the Scaphoid Bone 
\ 7. Dislocations of the Cuneiform Bones 



931 
931 
943 
945 
946 
947 
947 
948 



CHAPTER XXIV. 
Dislocations of the Metatarsal Bones . 



950 



CHAPTER XXV. 
Dislocations of the Phalanges of the Toes . 



952 



CHAPTER XXVI. 
Compound Dislocations of the Long Bonks 



954 



CHAPTEB XXVI I. 

Congenital Dislocations 

\ 1. General Observations and History 

\ 2. Etiology 

\ '■',. Congenital Dislocations of the Inferior .Maxilla 

\ 4. Congenital Dislocations of the Spine 

\ ">. Congenital Dislocations of the Pelvic Bones 

\ 6. Congenital Dislocations of the Sternum 

\ 7. Congenital Dislocations of the Clavicle 



970 
970 
970 
974 
977 
977 
978 
978 



CONTENTS. 



g 8. Congenital 1 lislocations of the Shoulder (Upper End of the Humerus) 

g 9. Congenital Dislocations of the Radius and Ulna Backwards 

I 10. Congenital Dislocations of the Head of the Had! 

\ 11. Congenital Dislocations of the Wrist 

I 12. Congenital Dislocations of the Fingers 

g 13. Congenital Dislocations of the Hip . 

g 14. Congenital Dislocations of the Patella 

g 15. Congenital Dislocations of the Knee . 

g 16. Congenital Dislocations of the Tarsal Bones 

$ 17. Congenital Dislocations of the Toes . 



PAGE 

979 



984 
985 
985 
991 
993 
996 
996 



LIST OF ILLUSTRATIONS. 



FRACTURES. 



FIG. 

1. Transverse, serrated (denticulated), and oblique fracture. From author's 

collection ...... 

2. Perforating and longitudinal fracture 

3. Impacted extracapsular fracture of neck of femur — vertical section 

4. Fracture of the humerus of a turkey; united with fragments widel; 

separated. From a specimen in the author's cabinet 

5. Fracture of the shaft of the femur ; united with an oblique callus. From 

a specimen in the author's cabinet .... 

6. Application of the "roller," by circular and reversed turns 

7. Many-tailed bandage 

8. Application of the many-tailed bandage .... 

9. Bandage of Scultetus 

10. Wood and leather splint 

11. Starch bandage applied for a broken thigh 

12. Seutin's pliers ......... 

13. Opening of the apparatus with Seutin's pliers . 

14. u Apparatus immobile," applied over a compound fracture" 

15. Von Brun's plaster-cutter ....... 

16. Clavicle, united by ligamentous bands .... 

17. Tiemann <fc Co.'s apparatus for ununited fracture of the femur 

18. Physick's first case, after 28 years ..... 

19. Dietfen bach's drill for ununited fracture .... 

20. Biainard's perforator, reduced one-half .... 

21. Gaillard's instrument for ununited fractures 

22. Fergusson's case of permanent bending .... 

23. Partial fracture without restoration of the. bone to its natural 

24. Partial fracture of the clavicle without spontaneous restorati 

nature; taken three weeks after the accident 

25. Partial fracture, after union is consummated 

26. Mason's dressing ..... 

27. Goffres's modification of Graefe's apparatus 

28. Fracture of the lower jaw .... 

29. Bean's maxillary articulator 

30. Bean's apparatus for broken jaw, applied . 

31. Houzelot's apparatus ..... 

32. Pla>ter model of jaws .... 
33 Kingsley's apparatus, applied to model 
34. Same applied to patient .... 



36 
36 



41 

63 
63 
64 
64 
69 
72 
72 
74 
75 
78 
86 
90 
90 
91 
92 
94 
99 
104 

104 
105 
115 
125 
134 
150 
151 
153 
154 
155 
155 



LIST OF ILLUSTRATIONS. 



FIG. 

35. Gibson's bandage for a fractured jaw .... 

86. Barton's bandage for a fractured jaw .... 

87. Four-tailed bandage or sling for the lower jaw 

38. The author's apparatus for a broken jaw .... 

39. Fracture of the spinous process ...... 

40. Fracture of the vertebral arch ...... 

41. Oblique fracture of the body of a vertebra 

42. Key's case of fracture in the first lumbar vertebra 

43. Wire-bed 

44. Bonnet's vertebral gutter ....... 

45. Parker's case of fracture of the odontoid process of the axis 

46. Development of sternum ....... 

47. Fracture of the ribs, with lateral union . 

48. Complete oblique fracture of the clavicle .... 

49. Fracture of the clavicle outside of the trapezoid ligament 

50. Complete oblique fracture of the clavicle at the outer end of the 

two-thirds ........ 

51. Comminuted fracture of the clavicle ; united . 

52. Figure-of-8 bandage, for a fractured clavicle . 

53. Moore's apparatus for fractured clavicle. Back view 

54. Moore's apparatus for fractured clavicle. Front view 

55. Sayre's apparatus for fractured clavicle 

56. Sayre's apparatus for fractured clavicle 

57. Sayre's apparatus for fractured clavicle 

58. Fox's apparatus for fractured clavicle 

59. The author's apparatus for fractured clavicle 

60. Fracture of angle of scapula 

61. Comminuted fracture of the glenoid cavity 

62. Fracture of the neck of the scapula . 

63. Scapula with epiphyses .... 

64. Fracture of the coracoid process 

65. Fracture at the anatomical neck of the humerus 

66. Pope's specimen of supposed fracture at the anatomical neck of the 

humerus, and reversion of the head 

67. Same 



68. Humerus, with epiphyses . 

69. Upper epiphysis of humerus 

70. Upper epiphysis separated 

71. Fracture of surgical neck of humerus 

72. Plan of author's long leather arm splint 

73. Long leather splint closed at top, and in shape . 

74. Short splint 

75. Lonsdale's apparatus for extension, in fractures of the humeru 

76. Clark's extension in fractures of the humerus . 

77. Fractures of the humerus at the base of the condyles 

78. Separation of lower epiphysis 

79. Reeve's case of separation of the lower epiphysis of the humerus 

80. Lange's case of separation of lower epiphysis, and detachment of epi 

dyles 

81. Hose's arm and forearm splint . 

82. Welch's arm and forearm splint 



290 



296 



LIST OF ILLUSTRATIONS. 



FIG. 

83. Bond's elbow splint 

84. The author's elbow splint 

85. Fracture at the base of the condyles of the humerus, and between the 

condyles ............ 

86. Separation of epiphyseal portion of internal epicondyle of the humerus . 

87. Fracture of the external epicondyle ....... 

8S. Eracture of the internal condyle of the humerus . . . . . 

89. Fracture of external condyle ......... 

90. Fracture of the head of radius 

91. Miitter's specimen of fracture of the neck of the radius . 

92. Scott's apparatus for fractures of the forearm 

93. Fracture of the shaft of the radius 

94. Colles's fracture — radius near its lower end 

95. Impacted fracture. Author's collection 

96. Comminuted fracture. Author's collection ...... 

97. Bigelow's case of comminuted fracture of the lower end of the radius . 

98. Transverse fracture of lower end of radius ; caused by forced palmar 

flexion ............. 

99. Transverse fracture of lower end of radius ; caused by forced dorsal 

flexion ............. 

100. Fracture at base of styloid process of radius, and laceration of annular 

ligament 

101. Nekton's splint for fracture of the radius near its lower end . 

102. Bond's splint for fracture of the lower end of the radius 

103. Hay's splint for fracture of the lower end of the radius .... 

104. E. P. Smith's splint for fracture of the lower end of the radius — front 

view ......... 

105. Same as above — back view ..... 

106. Hewit's splint 

107. Levis's metallic splint 

108. Author's palmar splint ; right arm .... 

109. Author's dorsal splint 

110. The author's dressing for a fracture of the radius near 

complete 

111. Radius, with epiphyses ...... 

112. Fracture of the olecranon process at its base . 

113. Olecranon process united by ligament 

114. Sir Astley Cooper's method of dressing a fracture of 

process ........ 

115. The author's splint for a fracture of the olecranon process, applied 

116. Fracture of the coronoid process of the ulna . 

117. Ulna, with epiphyses 

118. Fracture of the shaft of the ulna .... 
110. Fracture of the radius and ulna in the middle third 

120. Fracture of the radius and ulna in the lower third . 

121. Radius and ulna united with displacement 

122. Palmar splint 

123. Gutta-percha splint for finger 

124. Development of os innominatum .... 

125. Clark's case <>f comminuted fracture of the pelvis 

126. "Walker'- case of fracture of the acetabulum 



its lower end- 



PAGE 

296 
297 

298 
306 
310 
311 
314 
319 
321 
324 
325 
327 
330 
330 
330 

334 

334 



341 
342 
342 

342 
343 
343 
348 
348 
348 



357 
359 



the olecranon 



362 
302 
366 
368 
376 
380 
381 
381 
390 
398 
400 
401 
414 



LIST OF ILLUSTRATIONS. 



11... 
L27. 
128. 
129. 
L80. 
131. 
L82. 
133. 
134. 
135. 
136. 
137. 

138. 

139. 
140. 
141. 
142. 
143. 
144. 
145. 
146. 
147. 
148. 

149. 
150. 
151. 
152. 
153. 
154. 
155. 
156. 
157. 
158. 
159. 
160. 
161. 
162. 
163. 
164. 
166. 

166. 

167. 
168. 
169. 
170. 
171. 
1 72. 
173. 



Development of femur 

Fracture of the neck of the femur, within the capsule 
Intracapsular fracture, caused by a fall upon the trochanter 
Impacted fracture of the neck of the femur, within the capsule 
Horizontal section of the neck of the femur .... 



PAGE 

. 418 

. 422 

. 422 

. 423 

. 428 

Extracapsular fracture, with inversion 428 

Vertical section of Mrs. Wakelee's femur, acetabulum, and capsule . 434 

Impacted fracture within the capsule 434 

Section of the head and neck of the sound femur of an adult . . . 436 

Chronic rheumatic arthritis, in hip-joint 437 

Crosby's specimen of fracture of neck of femur within the capsule — un- 
united ............. 440 

Mayo's specimen of fracture of the neck of the femur within the capsule 

— united by ligament 440 

Author's apparatus for fractures of the neck of the femur . . . 441 

Gibson's modification of Hagedorn's thigh splints ..... 442 

Gibson's modified splint applied ........ 442 

Impacted extracapsular fracture . . . . . . . 447 

Same 447 

Same 447 

Fracture of the neck of the femur ........ 449 

Extracapsular fracture of the neck of the femur — ununited . . . 451 

Extracapsular fracture of the neck of the femur — with excess of callus . 451 
Extracapsular fracture of the neck of the femur — united with irregular 

callus ............. 452 

Miller's splint for extracapsular fractures 453 

Sir Astlej' Cooper's imaginary fracture 454 

Mr. Aston Key's case ... 456 

Physick's thigh splint 465 

Liston's dressing of fractured femur with a straight splint . . . 467 

Double-inclined plane formerly employed in Middlesex Hospital, London 470 

Amesbury's double-inclined plane ........ 471 

Amesbury's splint applied ......... 471 

Boyer's thigh splint applied ......... 472 

Nathan K. Smith's suspending apparatus, or double-inclined plane . 473 

Nott's double-inclined plane 473 

N. K. Smith's anterior splint 473 

N. K. Smith's anterior splint, applied 474 

Palmer's modification of the anterior splint 475 

Hodgen's suspension apparatus ........ 476 

Neill's straight thigh-splint, for extension and counter-extension . . 476 
Flagg's thigh apparatus — employed in the Massachusetts General Hos- 
pital. Pelvic belt and perineal straps 477 

Same — foot-piece and screw 477 

Same — lateral view of the apparatus, without the belt .... 477 

Same — front view, with folded sheets laid across ..... 477 

Same — apparatus applied, front view ....... 477 

Same — apparatus applied, side view 478 

Same — mode of applying adhesive plasters to leg ..... 478 

Same — mode of making extension by adhesive plasters .... 478 

Same — Perineal band secured with a padlock 478 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

174. GurdoD Buck's fracture apparatus 479 

175. Horner's thigh-splint ... 480 

176. Joseph Hartshorne's thigh-splint 480 

177. Gilbert's extension in fracture of the thigh ...... 481 

17S. Gilbert's extension applied to both thighs 481 

179. H. L. Hodge's counter-extension in fracture of the femur . 482 

180. Lente's thigh-splint 482 

181. Burge's apparatus for fracture of the femur 483 

182. Burge's apparatus applied ......... 483 

183. T. W. Simmon's suspension-extension apparatus ..... 484 

184. Dr. Gibbes's case, posterior view ........ 493 

185. Dr. Gibbes's case, anterior view ........ 493 

186. Extension during application of plaster of Paris ..... 495 

187. Extension continued until the plaster is hard 495 

188. Badly united fracture of femur, treated without permanent extension . 497 

189. Fracture of femur just below trochanter minor 497 

190. E. Daniel's invalid-bed 503 

191. Crosby's invalid-bed, closed 504 

192. Crosby's invalid-bed, open 504 

193. Standard for extension .......... 505 

194 Iron upright and weight 506 

195. Foot-piece . 506 

196. Extension-band and foot-piece ......... 507 

197. Extension-band and foot-piece folded ....... 507 

198. Mode of applying adhesive plaster for extension ..... 508 

199. Author's dressing for fracture of shaft of femur, complete . . . 509 

200. Author's splint for fracture of femur in a child . . . . .511 

201. Author's dressing for fracture of femur in a child — complete . . . 511 

202. Fracture of the shaft of the femur at the base of the condyles . . . 516 

203. Crosby's specimen of fracture of the external condyle of the femur . . 524 

204. Sir Astley Cooper's case of fracture of the external condyle of the femur 524 

205. Fracture of the internal condyle 526 

206 Transverse fracture of the patella 538 

207. Comminuted fracture of the patella 538 

208. Transverse fracture of the patella — exhibiting the relations of the muscles 

to the fracture 539 

209. Fragments of a broken patella separated by flexion of the knee . . 540 

210. Upper fragment of a broken patella drawn up very much by the action of 

the quadriceps feinoris .......... 540 

211. Dr. Kendig's case of fracture of the patella, front view .... 548 

212. Same — side view 548 

213. Bony union after fracture of the patella ....... 549 

214. Malgaigne's hooks for fractured patella ....... 550 

215. Dorsey's patella splint 556 

210. Sir Astley Cooper's method for broken patella by circular and parallel tapes 556 

217. Sir Astley Cooper's method by a leather band and counter-strap . 556 

218. Lonsdale's apparatus for fractured patella ...... 557 

219. Lau-dale's apparatus for fractured patella ...... 567 

220. Beach's apparatus . 667 

221. Beach's apparatus applied ......... 568 

222. Turner's apparatus 668 



LIST <>F ILLUSTRATIONS. 



ight foot 



elf 



and coun 



rii:. 

223. The author's mode of dressing a fractured patella 

224. The author's wooden inclined-plane for fractures of patella 

225. Wood's apparatus 

226. Development of tibia .■ 

227. Development of fibula 

22&. Fracture of the fibula near its lower end .... 

229. Vertical and transverse section of the tibio-tarsal articulation 

230. Dupuytren's splint incorrectly applied .... 
281. Dupuytren's splint, as originally made and applied hy himsel 

232. Compound and comminuted fracture of the leg 

233. Plaster-of- Paris dressing for fracture of leg, and suspension 

234. Van Wagenen's suspension apparatus . . . 

235. G. Wackerhagen's method 

236. Hutchinson's splint for extension in fractures of the leg . 

237. Neill's apparatus for fractures of the leg requiring extension and counter- 

extension ....... 

238. Neill's apparatus for compound fractures of the leg 

239. Gilbert's fracture-box 

240. Crandall's apparatus for fracture of the leg requiring extension 

ter-extension — side view 

241. Same — posterior view of the entire apparatus . 

242. Same — posterior view of the lower section 

243. Liston's double-inclined plane, applied to the leg in a case of 

fracture 

244. Bauer's wire splints for the leg 

245. Swing box for fractures of the leg 

246. Salter's cradle for fractures of the leg .... 

247. John W. Trader's suspension apparatus for compound fractun 

248. Fracture-box for the leg, with movable sides . 

249. Wire-rack for fracture of the leg 

250. Alalgaigne's apparatus for certain oblique fractures of the lei 

251. Malgaigne's apparatus applied 

252. Apparatus for fracture of the tuberosity of the calcaneum 

253. Author's movable canvas for gunshot fractures of thigh . 

254. Author's movable canvas for gunshot fractures of thigh 

on " horses " 

255. Hodgen's apparatus for gunshot fractures of the thigh 

256. Same 

257. Gunshot wound of spine . 

258. Same ' . 

'2')'.i. Gunshot fracture of thigh — side view 

260. Same — front view .... 



with 



compound 



extension 



LIST OF ILLUSTRATIONS. 



DISLOCATIONS. 

FIG. 

261. Clove-hitch 

262. Compound pulleys and ring 

263. Double dislocation of the inferior maxilla ..... 

264. Same 

26-3. Ayres"s case of bilateral dislocation of the fifth cervical vertebra 

266. Dislocation of the sternal end of the clavicle forwards 

267. Sir Astley Cooper's apparatus for dislocated clavicle 

268. Dislocation of sternal end of clavicle upwards 

269. Dislocation of the acromial end of the clavicle upwards . 

270. Dislocation of acromial end of clavicle upwards and outwards . 

271. Mayor's apparatus for dislocated clavicle ...... 

272. Dislocation of the shoulder downwards into the axilla 

273. Dislocation downwards, showing the untorn portion of the capsular 

ligament ........... 

274. Dislocation of the shou n der downwards into the axilla 

275. Xew socket in an ancient dislocation of the shoulder downwards 

276. N. R. Smith's method of reducing a dislocation of the shoulder 

277. La Mothe's method of reducing a dislocation of the shoulder — modified 

278. Sir Astley Cooper's method, with the heel in the axilla . 

279. Sir Astley Cooper's method, with the knee in the axilla . 

280. Iron knob employed by Skey instead of the heel .... 

281. Skey 's method in dislocations of the shoulder ... 

282. Sir Astley Cooper's method by means of pulleys .... 

283. Indian puzzle, employed to make extension in dislocations of the shoulder 

284. Subcoracoid dislocation of the humerus ...... 

285. Subclavicular dislocation of the humerus ...... 

286. Subcoracoid dislocation of the humerus, showing untorn posterior half 

of capsule 

287. Subcoracoid dislocation of the humerus ...... 

288. Subspinous dislocation of the humerus ...... 

28- ( . Dorsal dislocation of the humerus, showing untorn anterior half of 

capsule 

290. Albert's case — double upward dislocation of humerus — front view . 

291. Same — side view .......... 

292. Displacement of the long head of the biceps ..... 

293. Dislocation of the head of the radius forwards — anatomical relations 

294. Dislocation of the head of the radius forwards — external appearance 

of limb ............ 

296. Dislocation of the head of the radius backwards 

296. Dislocation of the upper end of the ulna backwards 

'ZU~. Dislocation of the radius and ulna backwards . . . . 

298. Sir Astley Cooper's method in dislocation of the radius and ulna 

backwards 

299. Wylie's case of complete outward dislocation of forearm . 
Same — arm nearly extended 

301. Most frequent form of incomplete outward dislocation of the forearm 



637 
640 
641 
659 
668 
670 
673 
677 
677 



695 
700 
701 
702 
703 
703 
704 
704 
706 
721 
721 

722 
723 
731 



736 
736 
740 
745 

745 

751 
753 
755 

769 
766 

7»i7 
768 



XXX LIST OF ILLUSTRATIONS. 

FIG. PAGE 

802. Most frequent form of incomplete inward dislocation of the forearm . 773 

303. Canton '8 case — dislocation of the radius and ulna forwards . . . 775 

304. Dislocation of the carpal bones backwards 783 

305. Same 784 

306. Dislocation of the carpal bones forwards — skeleton 785 

307. Dislocation of the carpal bones forwards 785 

308. Dislocation of lower end of ulna forwards ...... 788 

309. Partial backward luxation of metacarpal bone of thumb .... 792 

310. Dislocation of the first phalanx of the thumb backwards . . . . 796 
811. Clove hitch 798 

312. Sir Astley Cooper's method of reducing dislocations of the thumb by the 

pulleys 798 

313. Levis's instrument for reduction of the phalanges 801 

314. Same 802 

315. Indian puzzle, employed in the reduction of dislocations of small joints . 802 

316. Backward dislocation of the first phalanx of the index finger — reduction 

by extension 804 

317. Dislocation of the second phalanx backwards 806 

318. Dislocation of the second phalanx forwards . . . . . . 806 

319. Dislocation of the femur upon the dorsum ilii 812 

320. Ilio-femoral ligament 813 

321. Dislocation of the femur upon the dorsum ilii, showing relations of ilio- 

femoral ligament 814 

322. Dislocation upon the dorsum ilii — anterior view ..... 815 

323. Same — posterior view 815 

324. Dislocation of the femur upon the dorsum ilii ...... 816 

325. Everted dorsal dislocation 818 

326. Nathan Smith's method of reduction of a dislocation of the head of the 

femur upon the dorsum ilii, by manipulation ..... 823 

327. Relaxation of the ilio-femoral ligament by flexion ..... 825 

328. Hippocrates's mode of reducing dislocations of the hip by extension . 826 

329. Reduction of a dislocation upon ihe d >rsum ilii by pulleys . . . 827 

330. Reduction of a dislocation upon the dorsum ilii by the Spanish windlass 828 

331. Jarvis's adjuster — applied in dislocation of the hip 828 

332. Bloxbam's dislocation tourniquet — applied for reduction of a dislocation 

of the femur upon pubes 829 

333. The author's method of manipulation in dislocations upon the dorsum 

ilii — first position 835 

334. Same — second position 836 

335. Same — third position 837 

336. Bigelow's tripod for vertical extension 840 

337. Dislocation of the femur upwards and backwards into the great ischiatic 

notch • 841 

338. Same ." 841 

339. Internal obturator in its natural position 842 

340. Condition of anterior half of capsular ligament in " backward " dislocation 843 

341. Internal obturator in its new position 844 

342. Dislocation upwards and backwards into the great ischiatic notch — 

"below the tendon," when the patient is recumbent .... 844 

343. Reduction of a di.-location into the great ischiatic notch, by pulleys 848 

344. Relations of the ilio-femoral ligament to thyroid dislocations . . . 850 



LIST OF ILLUSTRATIONS. 



XXXI 



FIG. 

34:5. Dislocation of the femur downwards and forwards into the foramen 
thyroideuni ........ 

346. Tense, untorn, upward and backward portion of capsular ligament in 

thyroid dislocation 

347. Degree of flexion in thyroid dislocation if the ilio-femoral portion of 

capsule remains untorn ...... 

348. Reduction of thyroid dislocation by manipulation . 

349. Sir Astley Cooper's mode of reducing recent dislocations of the femur into 

the foramen thyroideum ...... 

350. Effect of flexion upon the ilio-femoral ligament in the thyroid dislocation 

351. Specimen of dislocation upon the pubes, in St. Thomas's Hospital 

352. Dislocation upon the pubes below the anterior inferior spine of the ilium 

353. External view of pubic dislocation 

354. Anterior view of pubic dislocation .... 

355. Dislocation upwards and forwards upon the pubes . 

356. Reduction of dislocation upon the pubes by extension 

357. Subspinous dislocation ....... 

358. Supraspinous dislocation ....... 

359. Anterior oblique dislocation ...... 

360. Mechanism of anterior oblique dislocation 

361. Voluntary subluxation upon the dorsum ilii 

362. Same 

363. Dislocation of the patella outwards ..... 

364. Dislocation of the patella inwards 

365. Complete dislocation of the head of the tibia backwards . 

366. Subluxation of the head of the tibia forwards . 

367. Subluxation of the head of the tibia outwards . 

368. Subluxation of the head of the tibia inwards . 

369. Dislocation of the lower end of the tibia inwards 

370. Same 

371. Reduction of a dislocation of the ankle by pulleys . 

372. Dislocation of lower end of the tibia outwards . 

373. Partial dislocation of the tibia forwards, with fractures of 

internus and fibula — skeleton 

374. Partial dislocation of the tibia forwards, with fracture of the 

internus and fibula 

375. Dislocation of the lower end of the tibia backwards . 

376. Same 

377. Dislocation of the astragalus outwards — anatomical relation: 

378. Simple dislocation of the astragalus outwards . 

379. Compound dislocation of the astragalus inwards 



malleolus 



malleolu: 



PAGE 

850 
851 

851 

854 

855 
856 
857 
858 
859 
859 
860 
862 
864 
866 
867 
868 
886 



904 
906 
909 
910 
916 
918 
919 
921 

923 

923 
926 
326 
931 



933 



PART I. 



FRACTURES 



FRACTURES. 



CHAPTER I. 

GENERAL DIVISION OF FRACTURES. 

Fractures are divided into Complete and Incomplete, Simple, Com- 
minuted. Compound, and Complicated. 

A Complete fracture is one in which the line of division completely 
traverses the bone. 

An Incomplete fracture is a partial separation of the bone: under 
which name are included Bending, Partial fractures, Fissures, Indented 
fractures, and Punctured or Perforating fractures, the last of which 
is almost peculiar to gunshot injuries. 

A Simple fracture is one in which the bone is broken at only one point. 
The term has no reference to the question of complications, but in its 
technical meaning, as employed by both English and American surgeons, 
it has reference only to the number of fragments into which the bone is 
broken. It would be more correct, perhaps, to substitute the word 
" single" for "simple," as has been done by Malgaigne and some other 
French writers, but I fear that to American surgeons the substitution 
would be rather a source of confusion than otherwise. 

A Comminuted fracture, called by Malgaigne "multiple," is a fracture 
in which the bone is broken at more than one point, and in which, con- 
sequently, the bone is divided into more than two fragments. It is used 
in a technical sense, and by no means implies minute division or commi- 
nution of the fragments. 

A Compound fracture is technically one in which there exists also an 
external wound communicating with the bone at the point of fracture. 
It may be either partial or complete, simple or comminuted, or even com- 
plicated, while at the same time it is also compound. 

Complicated fractures are such as present additional complications, or 
complications for which no other specific term has been invented. Thus, 
the fracture may be complicated with the lesion of an important blood- 
vessel or nerve, or with great contusion or laceration of the soft parts, 
with a dislocation, or with fractures of other bones, or even with some 
constitutional fault. 

Fractures are also divided into Transverse, Oblique, and Longitudinal, 
according as the direction of the line of separation is at a right angle 
with the axis of the bone at the point of fracture, or as it deviates more 
or less from this direction. But a fracture is called transverse when it 



GENERAL DIVISION OF FRACTURES. 



Fig. 1. 



w 



Transverse, ser- 
rated (denticula- 
ted) fracture. 



Oblique fracture. 
Called also V shaped. 
From author's col- 
lection. 

Fig. 2. 




Perforating and longitudinal fracture. 



does not traverse the bone precisely at a 
right angle; indeed, we usually apply 
this term whenever the obliquity is only 
moderate, or when, in the examination 
of a limb, although we are unable to 
detect the precise line of the fracture, 
we ascertain that, without being impacted 
or serrated, the ends of the bones continue 
to rest upon each other, or, being replaced, 
do not spontaneously become displaced. 

Longitudinal fractures occur generally 
in connection with oblique or transverse 
fractures ; as when the lower end of the 
femur is split vertically into the joint, 
and the shaft of the bone is traversed 
horizontally by a fracture which inter- 
cepts the vertical or longitudinal frac- 
ture. A fracture of a condyle, or of 
any projection from the body of the 
bone, is called longitudinal if the direc- 
tion of the line of fracture is parallel, 
or nearly so, to the axis of the shaft. 

A Serrated or Denticulated fracture 
is one in which the opposite surfaces 
denticulate, the elevations upon one frag- 
ment being reflected by corresponding 
depressions upon the other. 

Fig. 3. 




Impacted, extracapsular fracture of neck of 
femur. — Vertical section. 



Impacted fractures are those in which the fragments are driven into 
each other, the lamellated structure of one fragment penetrating the 
cancellous structure of the other. 



GENERAL ETIOLOGY OF FRACTURES. 37 

We speak also of fractures by avulsion, or arrachment, which are due 
in most cases to the action of the ligaments, but occasionally to the action 
of the tendons. They occur mostly in the vicinity of the joints, and con- 
sist in the separation of minute fragments or scales of bone, or of tuber- 
cles and tuberosities to which ligaments or muscles are attached, and 
occasionally of considerable portions of the articular ends of bones. 

Writers also occasionally speak of fractures en rave, en bee de flute, 
en bee de plume, as V-shaped, stellate, spiroid, cuneate, etc.; but we do 
not see the propriety of multiplying the divisions and encumbering our 
nomenclature by these fancied resemblances. For all useful purposes, 
the divisions above given are sufficient. 

Epiphyseal separations we shall not hesitate to class with fractures, 
and to submit them to the same rules of nomenclature. These accidents 
rarely occur after the twentieth year of life; since after this period, and 
in the case of some bones at a much earlier period, the epiphyses are 
usually united to the diaphyses by bone. A large proportion of these 
accidents seem to be due to arrachment, the epiplryses being torn off by 
the action of the ligaments or of the muscles. Suppuration and necrosis 
are more frequent sequences than in the case of true fractures. 



CHAPTER II. 

GENERAL ETIOLOGY OF FKACTTTEES. 

The causes of fracture may be considered as predisposing and exciting. 

Predisposing Causes. — Partial fractures, with bending of the bones, 
arc most frequent in infancy and childhood; but complete fractures 
occur most often during manhood; and if they are again less frequent 
in old age, it is because the exciting causes are less operative, since the 
fragility of the bones, as a general rule, increases with age. 

The influence of age as a predisposing cause of fractures consists in 
the changes which the bones undergo in advancing years by interstitial 
absorption, known as "senile atrophy." The interior or cancellated 
tissue is especially liable to this change; the cavities of the cylindrical 
bones becoming increased in size and filled with fat. 

It will be noticed, also, that somewhat in proportion as the bone is 
more brittle, its fracture will be more nearly transverse, so that very old 
persons have occasionally what has been not inaptly termed the "pipe- 
stem fracture:" but we must except from this rule fractures occurring 
in children, which are also sometimes transverse, often denticulated or 
splintered, and but rarely oblique. In all of the intermediate periods 
of life, oblique fractures are by far the most common. Females are Less 
liable to fractures than males, except in old age, when the law seem.-, in 
general, to be reversed. A- to ile- season of the year, it has been gener- 
ally observed by BurgicaJ writers thai fractures are more frequent in 
winter than in summer, and an explanation has been soughl for in the 



38 GENERAL ETIOLOGY OF FRACTURES. 

greater rigidity of the muscles during the cold weather, and the greater 
liability to falls upon the ice and frozen ground. Some have affirmed 
that the bones themselves were more brittle; but, aside from the im- 
probability of this last explanation, it is a matter of question whether 
fractures are actually more frequent in the winter than in the summer. 
If, on the one hand, the rigidity of the muscles and falls upon slippery 
walks are active causes in the production of fractures in the one season ; 
on the other hand, falls from buildings and accidents from a great variety 
of similar causes are equally active agents in the other. 

Mollities ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy, 
mercurialization, and, in short, all diseases dependent upon cachexia, 
are believed more or less to predispose to the occurrence of fractures. 
Grurlt thinks, however, there is no evidence that scrofula or gout predis- 
poses to fracture, and that .syphilis is not a very frequent cause. In- 
flammation of the periosteum, also, or of the bone itself, may predispose 
to fracture. It is said, moreover, that the bones of persons who have 
lain a long time in bed break easily. 

The liability to fracture is also sometimes hereditary, when there 
exists no recognized cachexia. In such cases, in the absence of any 
other explanation, we may suppose that the proportion of the earthy salts 
in the bones is increased ; but this supposition has not been confirmed 
by any observations known to the writer. 

Finally, trophic changes consequent upon disease of the nerve-centres 
may give rise to a fragility of the bones. It has been observed in luna- 
tics, the paralytic, and by Weir Mitchell 1 in persons affected with loco- 
motor ataxia. 

Remarkable examples of fragility of the bones have been from time to 
time recorded. Gibson relates the case of a young man who at the age 
of nineteen had suffered twenty-four fractures. Arnott speaks of a girl 
who at the age of fourteen had suffered thirty-one fractures; Esquirol 
had in his possession the skeleton of a woman in which were found traces 
of more than two hundred fractures ; and we have had, at the Charity 
Hospital, a man set. 53, who had suffered eleven fractures and two disloca- 
tions, in whose case the susceptibility both to fractures and to dislocations 
appeared to be hereditary. 2 In most of these cases, so far as is known, 
union occurred rapidly. 

Exciting Causes. — The exciting, determining, or immediate causes of 
fractures are of two kinds : mechanical violence and muscular action. 

Of these two, mechanical or external violence is much the most fre- 
quent cause; and this violence may operate in two ways: by acting 
directly upon the bone at the point at which it separates, and then we 
say the fracture is "direct," or from "direct violence;" or by acting 
upon some point remote from the seat of fracture, and then we say the 
fracture is " indirect," or from a "counter-stroke." When a person falls 
from a height, alighting upon his feet, and the leg or thigh is broken, 
the fracture is indirect; so also if the bone is broken by flexion or torsion. 
Even direct pressure upon one side of a long bone in a child may produce 

1 Weir Mitchell, Amer. Journ. Med. Sci., July, 1873, p. 113. 

2 The Physician and Pharmaceutist, Feb. 1870. Report by Armenag Assadoorian, 
House Surgeon. 



GENERAL ETIOLOGY OF FRACTURES. 39 

a partial fracture upon the opposite side, which is properly an indirect 
fracture: or a direct blow upon the trochanter major may occasion a 
counter-fracture through the neck of the femur. 

Fractures from muscular action occur most often in the patella, calca- 
neum. humerus, femur, tibia, and olecranon process of the ulna. These 
accidents may imply some condition of the bones themselves which pre- 
disposes them to fracture ; but I have seen one example of a fracture of 
the shaft of the femur in a large and perfectly healthy man, occasioned 
by a twist of the leg in rolling tenpins. I have also quite often known 
the tibia to break from natural muscular action in persons of uncommon 
vigor: and there is reason to believe that the patella is broken more 
often from muscular action than from direct force. Fractures sometimes 
occur in the violent contractions of the muscles during convulsions, and 
where no abnormal condition of the bones could be assumed to exist. 
Parker, of Xew York, relates a case of fracture of the humerus in a 
negro preacher, which occurred in the act of gesticulation ; also, a fract- 
ure of the clavicle occasioned by striking a dog with a whip ; in another 
case the humerus was broken in attempting to throw a peach; but the 
most singular case of all was a fracture of the humerus caused by an effort 
to extract a tooth. 1 

I myself have seen the clavicle broken in the case of a man who was 
reaching back to lift the top of his carriage; and another in which the 
humerus was broken in a contest to determine the power of the rotator 
muscles of the forearm. 

Lente has seen both femurs broken in epileptic convulsions, in a child 
twelve years of age. The left femur was broken April 10, 1859, at 
the junction of the upper with the middle third, and the right femur was 
broken at the same point eight months after, and about six weeks later 
he died. The first fracture united with considerable bowing and short- 
ening. The second did not unite at all. He had been subject to epilepsy 
since he was fifteen months old. 2 

Xearly all of the cases of fractures occasioned by muscular contraction 
seen by me were transverse, or nearly so, and most of those occurring in 
the long bones have been unattended with shortening, the ends of the 
bones not becoming completely displaced from each other. The example 
of fracture of the shaft of the femur before mentioned, as having been 
broken in rolling tenpins, was, however, an exception. The limb was 
placed by the surgeon in charge, upon a double inclined plane, upon the 
theory that in this position no shortening was likely to occur. The bone 
shortened, however, to the extent of an inch or more, and in this position 
it has finally united. 

Intra-uterine fractures are not yet fully explained, but it is probable 
that they, like extra-uterine fractures, may be ascribed sometimes to 
external violence, and at other times to simple muscular contraction, both 
perhaps acting upon bones already somewhat predisposed by a peculiar 
constitutional cachexy. 

November 18, 1872, a child was brought to me having a fracture of 

1 Parker. New York Journ. Med., July, 1862, p 96. 

2 Am. Med. Timea and Advertiser, July 21, 1800, p. 41. 



40 GENERAL ETIOLOGY OF FRACTURES. 

the left clavicle, which bad united with considerable deformity, the point 
of fracture being at the junction of the middle and outer thirds. The 
mother said that she fell upon her belly about two weeks before the birth 
of the child, striking upon a tub ; delivery occurred at the full period, 
in the hands of an uneducated female accoucheur. Four weeks later 
(when 1 was consulted) union was complete. 

Lawrence Proudfoot, of New York, has related a case of compound 
fracture in utero occurring in the practice of Dr. Freeman, which was 
apparently caused by external violence. Mrs. F., set. 38, always having 
enjoyed good health, during the sixth month of gestation, while attempt- 
ing to pass through a very narrow passage, was severely pressed upon 
the abdomen, and immediately experienced a severe pain in that region, 
accompanied with nausea and faintness. The following day, uterine 
hemorrhage, with pain, commenced; and these symptoms continued at 
intervals, in a form more or less severe, up to the period of her delivery, 
which occurred at full time, and was perfectly natural. At birth, the 
right foot of the child, a female, was found to be much distorted, and in 
a condition of valgus with equinus, the outer side of the foot being laid 
against the side of the leg above the external malleolus. The tibia, also, 
of the same limb, near its middle, seemed to have been the seat of a 
compound fracture ; the two ends of the bone having united at an angle 
slightly salient anteriorly, and the skin presenting over the point of 
fracture an old cicatrix. The soft tissues adjacent were considerably 
thickened. Seventeen months after birth, when the child was seen by 
Drs. Proudfoot, Van Buren, and Isaacs, the foot, although much improved 
by the means employed by Dr. Freeman, was still considerably deformed, 
in consequence of contraction of the tendo Achillis; on cutting which, 
the limb was found to be of the same length with the other. 1 

Dr. Aristide Rodrigue, of Hollidaysburg, Pa., has communicated a case 
of fracture with dislocation, which he ascribes to a similar cause. The 
woman, when about four months with child, fell on her left side, striking 
upon a board, and hurting herself severely. At the full period she was 
delivered of a well-grown male child. Its left humerus was found to be 
dislocated into the axilla, and both the radius and ulna of the same limb 
had been broken through their lower thirds, but were now united by bony 
callus at an angle of about 45°, and slightly overlapped. In all other 
respects the child was perfect. It does not appear that anything was 
done to the fracture, and the attempt to reduce the humerus was unsuc- 
cessful. Four years later Dr. R. saw the lad, and found him strong and 
hearty, the dislocated humerus having grown nearly at the same rate 
with the opposite, but the forearm remained "short and deformed as at 
birth." The hand was of the same size as the hand of the sound limb. 2 

Devergie has given an account of a woman, who, when seven months 
with child, struck her abdomen against the corner of a table. Intense 
pain followed, lasting some time. She went her full period, however, 
and the child was then found to have a fracture of the left clavicle, the 
fragments being overlapped somewhat, and united in this position by a 

1 Proudfoot, New York Journ Med., Sept. 1846, p. 199. 

2 Rodrigue, Amer. Journ. Med. Sci., Jan. 1854, p. 272. 



GENERAL ETIOLOGY OF FRACTURES. 41 

firm and large callus. 1 A woman also six months gone met with a similar 
accident, and ar the full time she gave birth to a feeble child, having in 
one leg a separation of the shaft of the tibia from its lower epiphysis. 
The end of the shaft was necrosed, and projected through a wound in the 
integument. This child died on the thirteenth day. 2 

Schubert reports the case of a female delivered before her term, of 
twins, one of whom was born with a fracture of the left thigh, which had 
occurred in utero ; the fractured bone had pierced the flesh, through 
which it projected more than an inch, and it was carious. The mother 
stated that about six weeks before the accouchement, during a movement 
of the foetus, she had heard a noise like that produced by breaking a 
stick, and from that moment she had felt pricking pains in her belly. 3 
It is probable that in this instance the fracture was the result of a mus- 
cular action, although it is possible that it was occasioned by the thigh 
having become entangled between the legs of the twin. Similar cases 
have been recorded by Ploucquet, Kopp, Carus,. Sachse, Moffat, and 
Brodhurst. 4 

In many other examples upon record 5 the explanation is plainly 
enough to be sought for in the abnormal or rachitic condition of the 
bones. Monteggia saw. in a newly born infant, twelve united fractures. 
Chaussier. who has published a memoir upon this subject, mentions two 
very extraordinary cases, in one of which the child presented forty- 
three fractures, and in the other, one hundred and twelve. 6 I myself 
was permitted to see, on the 29th of June, 1853, with Drs. Hawley and 
White, of Buffalo, an infant only four days old, who was born at the 
full time, of a healthy mother, in whom nearly all of the long bones 
were separated and movable at their epiphyses, the motion being gener- 
ally accompanied with a distinct crepitus. The bones were also much 
enlarged in their circumference ; the bones of the forearm and the femur 
were greatly curved : the fontanelles unusually open, and the clavicles 
were entirely wanting. The child was of full size, but looked feeble. 
It died in a condition of marasmus six months after birth, at which time 
some degree of union had taken place at several of the points of sepa- 
ration, the limbs having been supported constantly with pasteboard splints 
and rollers. 

Fractures occurring from violence inflicted upon the child by the 
accoucheur, or from contractions of the neck of the womb while the 
child i- in transitu, are more common occurrences, and do not require a 
separate consideration. I shall mention several in connection with the 
various bones in which they have taken place ; among which, one of 
the most interesting is that published by Jacob H. Vanderveer, of Long 
Branch, X. J. The mother came to bed on the 18th of January, 1847, 
after a labor of more than twelve hours. It was a foot presentation : 

1 Devergie, Rev. Med., 1826. 

2 Malgaigne, from Archiv. Gen. de lied., t. wi. p. 288 

3 Arner. Journ. Mad. -< . May, 1828, p. 223 ; from Zeitsch. i'iir Staatsarz. von 
Henke, 7 Erg. H ft., p. 311. Holmes'e Surgery, vol. iv. p. - 

4 Holrnes'.~ Surgery, vol. iv. 827, from M <<i.-( hir. Trans., vol. xliii. 18(H). 

Lond. Med. Times and Gaz , April 7. I860. New Orleans Med. Journ., Nov. 

6 Chaussier, Bullet, de la Faculte de \j , p [818, 801. 



4'2 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

the child weighed fourteen pounds, and was perfectly healthy, but one of 
the thighs had suffered a complete fracture, occasioned probably by the 
strong contractions of the cervix uteri. With careful splinting and 
bandaging, the bone was finally, but not without some difficulty, kept in 
position and made to unite, so that at the date of the report one would 
not discover that the bone had been broken, except by close inspection. 1 



CHAPTER III. 

GENEKAL SEMEIOLOGY AND DIAGNOSIS. 

• Fractures are liable to be confounded with contusions, and with 
various other local injuries, but most often with dislocations, and especi- 
ally when the fracture has taken place near one of the articulations is 
the differential diagnosis sometimes rendered exceedingly difficult. It is 
with particular reference, therefore, to the general points of distinction 
between fractures and dislocations, that I now propose to speak. The 
special signs or points of difference which belong to each individual case 
will be considered in their proper places. 

The most important general or common signs of fracture — and by 
" common " signs I mean those which are common to most fractures — 
are crepitus, mobility, and an inability on the part of the fragments to 
maintain their positions when reduced ; indeed, in many cases, this 
constantly recurring displacement is due to the fact that the surgeon is 
unable to accomplish a complete reduction. While, on the other hand, 
dislocations are almost as uniformly characterized by the absence of 
crepitus, by preternatural immobility, and by the fact that, when reduced, 
the bones do not usually require support to retain them in place, or 
indeed, we may say, by the fact that they are generally reducible. 

Let us study these phenomena a little more in detail. 

Crepitus, occasioned by the chafing of the broken surfaces upon each 
other, when actually present, is almost positive evidence of the existence 
of a fracture. It is possible, however, to confound the chafing of en- 
gorged tendinous sheaths, or of inflamed joints upon which fibrinous 
effusions have occurred, or of emphysema even, for the true crepitus of 
a fracture, but to the experienced ear and well-practised touch these 
sensations are seldom a source of error. The one is rough, crackling, 
even clicking sometimes, while the other is more subdued, and imparts a 
more uniform sensation to the hand, and but rarely conveys an actual 
sound, unless the ear is directly applied or the stethoscope is employed. 
It is only when the crepitus is transmitted obscurely through a great 
mass of soft tissues, or sufficient time has elapsed for the ends of the 
fragments to become softened by inflammation and partially covered 
with a plastic material, or when, indeed, a dislocation is actually coinci- 

1 Vanderveer, Amer. Journ. Med. Sci., May, 1847, p. 378. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 48 

dent with the fracture, that the surgeon is left in doubt. Occasionally, 
also, the existence of caries or of necrosis, in connection with a disloca- 
tion, might lead to the supposition of a fracture ; but the history of the 
case, aside from the remaining common signs, and the special symptoms 
hereafter to be enumerated, would prevent any possibility of error. In 
a few cases the diagnosis may be facilitated by the application of the ear 
or of the stethoscope, as first recommended by Lisfranc. 1 

It must not be forgotten, moreover, that a fracture at one point may 
transmit the sensation of crepitus distinctly enough, but in such a direc- 
tion, owing to the relations of other bones to the one broken, as to mis- 
lead the surgeon, and induce him to locate the fracture in the wrong- 
bone. Several examples of this species of deception I shall hereafter 
have occasion to mention. 

Valuable and important as is crepitus in its relations to differential 
diagnosis, unfortunately it is not always present, and for reasons which 
must be plainly stated. First. We cannot, in a pretty large proportion 
of cases, bring the broken ends again into apposition. Whatever mere 
theorists may say to the contrary, and notwithstanding surgeons up to 
this time have rarely ventured to allude to this subject, the fact is that 
we do not usually "set" broken bones. We do not, even at the first, 
bring them into complete apposition, unless it is as the exception. I 
speak of the bones once completely displaced by overlapping, and these 
constitute the majority of examples which come under the surgeon's 
observation. Second. In transverse fractures of the patella, and in 
fractures of the olecranon process of the ulna, of the acromion process 
of the scapula, and in all similar detachments of processes and apophyses, 
the action of the muscles, by displacing the fragments, may prevent 
crepitus from being readily produced. Third. In a few cases, such as 
certain fractures of the neck of the femur, of the neck and head of the 
humerus, in a Colles fracture, etc., the broken ends may be impacted, or 
so driven into each other as to forbid the production of motion and 
crepitus : or they may be simply denticulated, and the consequences, so 
far as crepitus is concerned, will be the same. 

Finally, in very many incomplete fractures, crepitus does not exist; 
and even when it is present, the sensation is feeble, or very much modi- 
fied, sometimes giving only a faint and single click. Under the head of 
crepitus Ave may properly include the sharp crack sometimes felt, or even 
heard, by the patient at the moment of fracture. 

Preternatural mobility, less valuable as a means of diagnosis than 
crepitus, is, nevertheless, more constantly present, being never absent, 
in some degree, in all complete, non-impacted, and non-denticulated 
fractures ; but its presence does not, like crepitus, render the existence 
of a fracture quite certain. Whenever the bony lesion takes place in the 
vicinity of a joint, it may be difficult or impossible to determine 
whether the mobility of the limb is due to motion in the joint or to 
motion at the Bupposed seat of fracture. While, on the other hand, the 
preternatural immobility bo generally observed in dislocations may give 
place to preternatural mobility, as when the ligaments and t<ii<!niis 

1 New England Med! Journ., L824, p. 220. 



44 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

surrounding the joint are extensively torn, or the system itself is labor- 
ing under the shock of the accident, or when from any other cause there 
exists great general prostration. 

As to the third common sign mentioned, namely, that broken bones do 
not generally support themselves, but demand for this purpose, in most 
cases, the interposition of splints, bandages, and even of extending and 
counter-extending forces, its authority rests upon the same evidence as 
does the assertion already made, that bones once separated entirely, can- 
not generally be "set," that is, placed again end to end in such a manner 
as to be made effectually to support each other. It rests upon the evi- 
dence of my own personal experience ; to which I am permitted to add, 
also, the personal experience of Malgaigne, who, with a frankness which 
does him great credit, and which, I am sorry to say, has hitherto found 
few imitators, remarks: "Second. That overlapping is the most stub- 
born of all. Here I will add a disagreeable truth, which classical 
authors have kept too much out of sight, namely, that it is so stubborn 
that in an immense majority of cases the efforts of art are unable to 
overcome it." 1 And it must be observed further, that if we shall often 
find it possible to bring the broken surfaces sufficiently into contact to 
develop crepitus, they may still be unable to maintain themselves in this 
position, owing to the obliquity of the line of fracture. 

The other common signs of fracture may be briefly stated. Pain at 
the seat of fracture ; swelling ; ecchymosis ; deformity, produced by 
either an angular, transverse, or rotatory displacement of the fragments, 
and which is quite as often due to the direction and force of the impulse 
which occasioned the fracture as to the action of the muscles ; separation 
of the fragments, as in fractures of the patella and olecranon process ; 
and inability to move the limb, a phenomenon due in part to the breaking 
of the bony lever upon which the muscles acted, and in part to the 
intense pain caused by any such attempts. This latter symptom is, 
however, often entirely absent. It is not generally present in impacted 
fractures, in serrated and partial fractures, or in many other fractures in 
w T hich the periosteum has not yet completely given way. 

Yelpeau w T as the first, I think, to call attention to the fact that 
patients with broken clavicles could very generally raise the arm above 
the shoulder and even to the head, and I have repeatedly verified the 
observation, notwithstanding the separation of the fragments has been 
complete, and the overlapping considerable. In fractures of the neck of 
the femur and of the tibia it is no uncommon thing for the patient to 
walk some distance after the receipt of the injury. 

As has been previously stated, fractures of long bones, caused by 
muscular action, generally occur near the middle of the shaft, and they 
are usually transverse. Direct fractures are also more nearly transverse 
than indirect fractures, but less so than those caused by muscular action ; 
while those indirect fractures which are caused by a force applied in the 
direction of the axis of the bone are, in general, very oblique. But 
what is of more importance in connection with diagnosis is, that in this 
latter class of. cases the fracture usually takes place near the point upon 

1 Malgaigne, Traite des Fractures etdes Luxations, Paris ed., t. i. p. 102. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 45 

which the force of the blow is received. Thus, for example, a fall upon 
the hand generally causes a fracture of the lower end of the radius — a 
Colles fracture — or if both bones break, it is generally below the middle, 
and very seldom indeed in the upper third. A fracture of the shaft of 
the humerus near the condyles is a frequent result of a fall upon the 
elbow. The classical fracture of the clavicle, at the junction of the 
middle and outer thirds, is usually caused by a fall upon the shoulder. 
A foil upon the foot causes a fracture, in most cases, near the lower end 
of the tibia, and the same is true, quite often, of the lower end of the 
femur. Exceptions to the rule above stated are most commonly met with 
in advanced life, when falls upon the elbow occasion fractures at the 
• surgical neck of the humerus, and falls upon the shoulder sometimes 
cause fractures near the sternal end of the clavicle. Similar accidents, 
in old people, also sometimes break the tibia near its upper extremity, 
and the femur within its capsule. 

I cannot dismiss this subject without calling attention to the necessity 
of exercising care and gentleness as well as skill in the examination of 
broken limbs. 

Nothing, in my opinion, betrays a lack of judgment as well as of 
common humanity, on the part of the surgeon, so much as a rude and 
reckless handling of a limb already pricked and goaded into spasms by 
the sharp points of a broken bone. It is not enough to say that such 
rough manipulation is generally unnecessary, it is positively mischievous ; 
provoking the muscles to more violent contractions, increasing the dis- 
placement which already exists, and sometimes producing a complete 
separation of the impacted, denticulated, transverse, or partial fractures, 
which can never afterwards be wholly remedied; augmenting the pain 
and inflammation, and not unfrequently, I have no doubt, determining 
the occurrence of suppuration, gangrene, and death. 

In proceeding to establish the diagnosis in any case, the surgeon 
should sit down quietly and patiently by the sufferer, so as to inspire in 
him from the first a confidence that he is not to be hurt, at least unneces- 
sarily. He ought then to inquire of him minutely as to all the circum- 
stances immediately relating to the accident, in order that he may deter- 
mine as nearly as possible its cause, which alone, to the experienced 
surgeon, often affords presumptive, if not conclusive, evidence as to the 
nature and precise point of the injury. From this, he should proceed to 
examine the disabled limb; removing the clothes with the utmost care 
by cutting them away rather than by pulling; and when completely 
exposed, he should notice with his eye its position, its contour, the points 
of abrasion, discoloration, or of swelling ; and not until he has exhausted 
all these sources of information, ought the surgeon to resort to the 
harsher means of touch and manipulation. Nor will his sensations guide 
him to the point of fracture by any other method so accurately as when. 
the patient being composed and his muscles at rest, he moves his fingers 
lightly along the surface of the limb, pressing here and there a little 
more firmly, according as a trifling indentation or elevation may lead 
him to suspect this or that to be the point of fracture. 

The limb, in case of a supposed fracture of a long bone, may now be 
measured with a tape-line, and compared with the opposite limb, having 



4l! REPAIR OF BROKEN BONES. 

first marked with a soft pencil or with ink the several points from which 
the measurements arc to be made. 

Finally, if any doubt remains, the limb must be firmly but steadily 
held while the necessary manipulations are performed, for the purpose of 
ascertaining the existence of mobility and of crepitus. Mobility is most 
easily determined by giving to the limb a lateral motion, but in general, 
crepitus is most effectually developed by gentle rotation. If the place of 
fracture is already pretty well declared by the previous examinations, 
the surgeon should place one finger over the suspected point, during this 
manipulation, by which means the crepitus will be more certainly 
recognized. 

I do not often find it necessary to resort to anaesthetics for the purpose 
of insuring quietude and annihilating pain in making these examinations, 
since it is seldom that the patient need to be much disturbed ; but if the 
examination is not satisfactory, and the diagnosis is important, I do not 
hesitate to render the patient completely insensible, after which the ques- 
tions in doubt may be more thoroughly investigated and perhaps definitely 
settled. 

The surgeon ought not to forget, however, that while the patient is 
under the influence of an anaesthetic, violent manipulations are no less 
liable to rupture bloodvessels, and to lacerate other tissues, than if em- 
ployed when the patient is conscious. Surgeons have not seemed always 
to understand this, and the result has been that in too many instances 
they have inflicted serious and irreparable injury; in one instance which 
came under my notice, the injury thus inflicted caused tetanus and death. 

It is scarcely necessary to say that the earlier the examination is 
entered upon, the more readily will the diagnosis be made out; and if, 
unfortunately, some time has already elapsed before the patient is seen 
by the surgeon, and much swelling has taken place, the examination is 
still not to be omitted; and whatever doubts remain we must endeavor 
to remove by repeated examinations, made from day to day, until the 
subsidence of the tumefaction has brought the surfaces of the bone again 
within the reach of our observation. 



CHAPTER IT. 

REPAIR OF BROKEN BONES. 

It is not my intention to enter very fully into a consideration of the 
process of repair in fractures, preferring to leave this subject where it 
more properly belongs, to the general treatises on surgical pathology. 

I only propose to state very briefly a few practical, and I trust I may 
now say, pretty well-established facts, such as the manner or position in 
which this reparative material, whenever it is employed, is applied to the 
broken bones, the length of time which is usually required for the com- 



REPAIR OF BROKEN BONES. 47 

pletion of the process of repair, and the causes which may impede or pre- 
vent bony union. 

If I think it necessary to say anything more upon this subject, it will 
be simply to announce my belief that the reparative material, consisting 
originally of a plastic lymph, is poured out from the vessels of the Haver- 
sian canals, the medullary tissue, the periosteum, and more or less from 
all of the lacerated tissues which are immediately adjacent to the seat of 
fracture : but probably in greatest abundance from the periosteum ; that 
after a period, longer or shorter, this lymph becomes organized, and 
begins to receive from the same sources particles of bony matter, through 
which the consolidation is finally effected ; that the transition from the 
original plastic material to bone is in adults almost constantly through 
the interposition of connective tissue, rarely, unless in the case of children, 
through a cartilaginous tissue, and sometimes through both consentane- 
ously or consecutively ; that, perhaps, in a few fortunate examples bones 
unite directly or immediately, without the intervention of a reparative 
material ; and finally, that granulation-tissue sometimes becomes trans- 
formed into bone, in certain cases of compound fractures, or of fractures 
in which the process of inflammation exceeds certain limits. 

Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel, 
Camper, and Haller, declared that "nature never accomplishes the im- 
mediate union of a fracture save by the formation of two successive 
deposits of callus;" one of which is derived from the periosteum, the 
adjacent tissues, and from the medulla; while the other, derived, perhaps, 
from the broken extremities of the bone itself, is found at a later period 
directly interposed between these surfaces. The material or callus 
derived from the tissues outside of the bone, and which Galen compared 
to a ferrule, but which Mr. Paget calls "ensheathing," together with 
the material derived from the medulla, compared often to a plug, and by 
Mr. Paget named "interior" callus, is by Dupuytren spoken of as the 
"provisional" or temporary callus, by which the fragments are sup- 
ported, and maintained in contact until the permanent callus is formed. 
This temporary splint is completed or has arrived at the condition of 
bone in a spongy form, at periods varying from twenty to sixty days; 
but it does not assume the character of compact bone until a period 
varying from fifty days to six months has elapsed; after which it is 
gradually removed by absorption. The second process, by which the 
ends of the bone are definitively or permanently united, commences when 
the provisional callus has arrived at the stage of spongy bones, and is not 
completed usually within less than eight, ten, or twelve months, "when," 
Dupuytren, "it acquires a solidity greater than the original bone." 

While it is certain that this eminent surgeon and most accurate ob- 
server has described faithfully the various phenomena which usually 
accompany the repair of bones in those animals which were the subjects 
of his experiments, and that his conclusions have a certain degree of 
application to the human species, it is equally certain that he erred in 
aaanmmg that in man simple fractures always unite by this double pro- 
yet, such is the power of* authority, these doctrines were accepted 
from the first without hesitation or debate, and for nearly half ;i century 
they have occupied the minds of surgeons, to the almosl complete exclu- 



4S B E P AIR O F B B K E N B XKS. 

Bioo of every other theory. Mr. Stanley was among the first to question 
the solidity of the doctrines of Dupuytren, but it remained for Mr. Paget 
to expose fully their many fallacies: nor lias Malgaigne, although not 
strictly a disciple of Paget, failed to detect certain of these errors. 

I should also do injustice to myself were I not to mention that at the 
very moment when Mr. Paget was making his observations upon the 
specimens in " the large collection of fractures in the museum of the 
University College," I myself was employed in similar researches both 
among cabinet specimens and in the hospitals of this country and of 
Europe: and that the conclusions to which I had arrived were nearly 
identical with, although the inferences were far from being so complete 
in their detail as those to which this distinguished pathologist was him- 
self brought. 1 I do not. however, wish to make Mr. Paget responsible 
for any of the opinions upon this subject which I shall hereafter express, 
except so far as they may be found to agree with his own published 
views. 2 

I think it may now be fairly stated that the repair of bones by the 
double process described by Dupuytren is. in man, only an exception to 
a very general rule: and that fractures may unite by either one of the 
following modes : 

First. Immediately, or in the same manner that the soft tissues some- 
times unite, by the direct reunion of the broken surfaces, and without 
the interposition of any reparative material. This happens probably 
sometimes in the spongy bones, and in the extremities or spongy por- 
tions of the long bones, especially when one portion of bone is driven 
into another and becomes impacted: as. for example, in some extracap- 
sular impacted fractures of the neck of the femur, in certain impacted 
fractures of the head or neck of the humerus, of the lower end of the 
radius, etc. 

Second. By interposition of a reparative material between the broken 
ends: as when the fragments remain in exact apposition, but immediate 
union foils. This is especially apt to occur, in superficial bones, such as 
the tibia: or upon those sides of the bone which are most superficial. It 
is not an unusual circumstance to find the shaft of the tibia during the 
process of union presenting no exterior callus upon its anterior and inner 
surface, whilst the posterior and outer section of its circumference is 
covered with an abundant deposit. In other cases, however, of fractures 
of the shaft as well as of the epiphyses, the intermediate callus secures a 
prompt union, but no ensheathing callus is ever formed. 

Third. Bones broken and not separated, unite occasionally by the 
process described by Dupuytren. namely, by the formation, first, of an 
ensheathing callus, whilst at the same moment the cylindrical cavity 
becomes closed by a spongy plug, or its canal is merely interrupted by a 
compact septum of bone ; and. second, by definitive callus deposited 
between the broken ends. It is probable that this happens generally in 
children, or during the periods of the greatest activity in the develop- 
ment of bones; and it is a common mode of union in the ribs, which 

1 Paper on ' : Provisional Callus," by Frank II. Hamilton. Buffalo Medical Journal. 
Feb. 18 

2 Lectures on Surgical Pathology, by James Paget. Phila. ed.. 18-54, Chapter XI. 



REPAIR OF BROKEN BOXES. 49 

bones, during the whole progress of the union, are necessarily kept in 
motion. My cabinet furnishes many illustrations of ensheathing callus 
in ribs : and also a few in fractures of the tibia and fibula. 

Fourth. Under similar circumstances, where no displacement exists, 
the fracture may unite by ensheathing and interior callus alone, no inter- 
mediate callus ever being formed between the broken ends; in which 
case it may be probably said that the bone itself has never united, and 
the ensheathing callus, instead of being provisional, is permanent or defi- 
nitive. This was essentially the doctrine of Galen, Haller, and Duhamel 
before Dupuytren added his "fifth period." or the formation of definitive 
callus : and by these older surgeons it was held to be of universal appli- 
cation, except, perhaps, in the case of children. To this doctrine also 
Malgaigne has returned ; at least to the question, " Is there always a 
definitive callus, or complete union of the fragments ': " he has made this 
laconic reply: "Galen admitted its occurrence, but only in young sub- 
jects : it has been obtained in animals, where there had been no displace- 
ment. I would willingly believe that such is sometimes the case in 
human adults ; but I must confess I have seen only the instance above 
cited, which might just as well be used to prove the compact ossification 
of the provisional callus.'" He accepts, therefore, the doctrine of Galen 
as having not merely an occasional application, but as explaining the 
process of union in the large majority of cases : and in support of this 
extreme view he finds that the exterior callus, which Dupuytren called 
provisional or temporary, is actually permanent, unless removed by the 
absorption consequent upon pressure. 

To all of which we can only say that an examination of five or six 
specimens in our own cabinet, after having carefully divided them with 
a saw. has furnished only one illustration of union by ensheathing and 
interior callus alone. In each of the other specimens the union was com- 
pleted by definitive or intermediate callus. We cannot, therefore, avoid 
the conclusion that Malgaigne has been deceived as to the relative fre- 
quency of these different modes of union, and that union without inter- 
mediate callus is exceptional. 

Fifth. When bones are broken and overlap, they may unite by the 
interposition of a callus between the opposing surfaces, that is, by an 
intermediate callus, but which will differ from that described as the 
second method, inasmuch as the new material will be deposited upon 
the sides of the fragments and not upon their extremities. The limb 
being kept perfectly at rest, and all other circumstances proving favorable, 
this union may take place without any excess or irregularity in the 
deposit. The surfaces will unite firmly where they are in actual con- 
tact : and smooth and well-formed buttresses will fill up all the spaces 
between the bones where they are not in actual contact, sufficient gen 
erally to give the requisite strength to this new bond of union. This 
mode of union will be completed sometimes when the two ends of the 
hours are separated laterally an inch or more from each other. \ have in 
my collection the bone of a turkey*.- thigh (Fig. 4) thus united by a 
transverse bony shaft, although separated more than one inch; and, what 
iiinon. I possess also ;i specimen of the adult human thigh 
(Fig. 5), in which an oblique shaft of solid callus has, after many months, 



50 



KEl'AIR OF BROKEN BONES. 



and while no splints were employed, bound together firmly the fr\vo 
opposite extremities of the broken bone. 

Sixtli. The fragments being overlapped more or less, and suffering 
unusual disturbance, or the adjacent tissues having been much torn, or 



Fig. 4. 



Fig. 





Fracture of the humerus of a turkey ; united with 
the fragments widely separated. From a specimen 
in the author's cabinet. 

much blood being effused, so that consid- 
erable inflammation is caused, the amount 
of callus will exceed what is necessary 
for the complete union of the bones ; and 
this redundancy may be deposited around 
and upon the broken ends of the bones, 
or anywhere in their immediate vicinity, 
in layers, or in masses of irregular shape 
and size. Even the bones which are not 
broken, but which are near, as in the 
case of the fibula after a fracture of the 
tibia, may become inflamed, or their cov- 
erings may inflame, and they may also 
contribute to the general mass of bony 
callus. 

Compound fractures, or rather, we ought 
to say, fractures accompanied with granu- 
lations and suppuration, obey no uniform 
law of repair, so far as the manner and 
position of the deposit are concerned ; but 
they come together finally with more or 
less irregular distributions of ossified mat- 
ter, according to the varying circumstances of imperfect coaptation, 
mobility, etc., in which they may chance to be placed. Occasionally the 
amount of callus is less than occurs in simple fractures, and at other 
times the excess is very great. 

That was, no doubt, a beautiful thought, which ascribed the formation 
of provisional callus to an intelligent efficient cause, which in this manner 
sought to support the fragments until a reunion of their divided ends 
was accomplished. But the beauty of a conception supplies no evidence 
of its truth ; and we have grave doubts whether Nature ever allows any 
interference with her laws even in an exigency, unless by the substitution 
of a miracle. Provisional callus is, in our opinion, just as much the 
necessary result of natural laws, as is definitive. It is formed because 




Fracture of the. shaft of the femur; 
united with an oblique callus. From 
a specimen in the author's cabinet. 



REPAIR OF BROKEN BONES. 51 

in that condition of the parts and of the general life its formation 
was inevitable. "Whether useful for the purposes of repair or not, it 
will, under certain circumstances, exist. In the repair of certain frac- 
tures, provisional callus, it is conceded, seldom occurs. Thus it is with 
the cranium, the acromion, coracoid and olecranon processes, the patella, 
and with all those portions of bones which are immediately invested with 
a synovial capsule. Will it be affirmed that in the examples just named 
this callus is not formed because it is not required? To us it seems that 
nowhere could it prove more useful, since, with the single exception of 
the cranium, it is in these very cases that the obstacles to a reunion are 
the most serious. In fractures of the patella, olecranon, etc., the action 
of the muscles tends constantly and powerfully to displace the fragments, 
and gladly would the surgeon avail himself of the assistance of a tem- 
porary callus, but it is rarely present, at least in any useful degree. So 
also in fractures of the neck of the femur within the capsule, and in 
other similar cases, we cannot say that temporary callus would not 
be advantageous in facilitating the retention of the fragments, yet the 
••intelligent efficient agent" neglects to furnish it. 

The only satisfactory reason which, as we think, can be assigned for 
the absence of callus in these cases, is found in the doctrines we now 
advocate: that is to say, it is usually absent because that amount of 
excitement and irritation is usually absent which alone determines its 
formation. In the case of the olecranon, patella, etc., the fragments 
being separated from each other by muscular action, so that no painful 
pinchings or chafings occur, and their rough surfaces or sharp points 
being rather drawn away from than protruded into the flesh, no sufficient 
provocation exists for the production of inflammation and effusion. 
Hence the failure of provisional callus; but wherever the fracture 
occurs, and however moderate the action, definitive callus does not fail ; 
still the broken surfaces of the patella and olecranon are softened, and 
smoothed, and covered over with a new matter, which, if contact could 
have been secured and preserved, would certainly have served to con- 
solidate and repair the breach. The natural reparative process proceeds, 
but only the accidental process is omitted. The latter, however, is seen 
again even here, when from other and unusual causes a sur-excitement is 
established. 

Temporary callus is not formed upon bones invested with synovial 
membranes, because here, too — as in the neck of the femur — there are 
not so many structures lacerated and irritated, and the supply of this 
effusion must be the less not only in proportion to the less intensity of 
the inflammation, but also to the less amount of structures implicated 

Possibly other and more satisfactory reasons may be assigned why 
provisional callus is not formed usually when the neck of the femur is 
broken within the capsule; but we certainly can never admit the com- 
mon, and. as here applied, the too palpably absurd explanation, that it 
is not wanted. It is wanted, and in no case so much as in the one now 
supposed. 

Provisional callus has, therefore, no final purpose, but it is the un- 
avoidable result of certain abnormal conditions. It still occurs every- 
where when against and in the vicinity of the bone there are the requi- 



52 



GENERAL PROGNOSIS. 



site lesion and action, and it will occur as certainly when there is no 
fracture at all, but only a caries, a necrosis, or a simple bony or perios- 
teal inflammation; and whilst it is doubtless true that in fractures it 
sometimes renders valuable aid to the surgeon, it is equally true that it 
often proves a source of hindrance. 

Dupuytren, in determining the limits of his "third " period, or of that 
in which a provisional callus is formed of sufficient strength to support 
the fragments, has given what has been usually quoted as the natural 
period within which bones may be said to be united, that is, " from the 
twentieth or twenty-fifth day, to the thirtieth, fortieth, or sixtieth." 
But this depends so much upon the age of the patient, his general con- 
dition of health, the condition and position of the broken ends, as well 
as upon the bone itself, and the point at which it is broken, with many 
other circumstances, that it would be unsafe to establish any absolute 
laws in reference to this point. 

In very early infancy, union is accomplished in half the time required 
in adult life, and it is generally thought to be still more retarded in 
advanced age, but Malgaigne has not found this latter observation con- 
firmed by his own experience ; nor have I observed any marked differ- 
ence, in this respect, between persons of middle and old age. 

Various constitutional causes, as we shall hereafter explain more fully, 
retard bony union. Motion, also, sometimes delays consolidation : frag- 
ments which are overlapped do not unite as speedily as those which are 
placed end to end ; and other complications interfere in a similar manner, 
such as lesions of nerves, of bloodvessels, comminution of the bone, the 
interposition between the ends of the fragments of a blood-clot, a por- 
tion of muscular, tendinous, or other tissue, etc. In general, the bones 
of the lower extremities, independently of their size, unite more slowly 
than the bones of the upper extremities. 

Epiphyses, when separated, unite by the same process as fractures of 
the bone. It is observed, however, that when certain epiphyses unite 
with much displacement, the shafts from which they have been separated 
cease to grow, or grow more slowly, and the limbs become atrophied. 

For a more complete consideration of the causes which retard the 
union of bones, I beg to refer the reader to the chapter on " Delayed 
Union, and Non-Union of Bones." 



CHAPTER V. 

GENERAL PROGNOSIS. 



The prognosis in fractures must vary greatly according to the place, 
character, and complications of the accident; and for this reason it is 
impossible to give anything beyond a few general maxims at this time, 
leaving the more precise and detailed statements until welcome to con- 
sider each individual fracture. 



GENERAL PROGNOSIS. 53 

We have already, in the preceding chapter, considered some of the 
points of prognosis, especially those relating to the average time in 
which bones unite, the causes of delayed union, and of non-union, etc. 

In general it may be said that simple, oblique fractures occurring in 
the shafts of long bones unite with some shortening. Indeed this rule 
presents but few exceptions. This is due to the overlapping or to the 
impaction, both of which we are in most cases unable completely to 
overcome. It is scarcely necessary to say that the inevitable result of 
such overlapping is a more or less manifest irregularity, or deformity at 
the seat of fracture. In general, however, the natural line of the axis 
of the limb may be preserved. 

Simple transverse fractures of the shafts of long bones, which are of 
rare occurrence, when completely displaced and made to slide past each 
other, are seldom effectually replaced, and are, like oblique fractures of 
the same class, apt to result in shortening and some deformity. 

All compound, comminuted, and complicated fractures, which in their 
very nature present additional obstacles in the way of complete adjust- 
ment and of proper support, are likely to entail deformity. Contrary, 
however, to what is generally supposed, certain compound fractures of 
the shaft of the femur, caused by thrusting a sharp fragment through 
the flesh and skin, if promptly reduced, unite as speedily and with as 
little deformity as simple fractures. 

Gunshot fractures, which are necessarily in most cases compound and 
comminuted, are in a much less degree amenable to treatment with ad- 
justing and supporting apparatus than are most other fractures, and they 
necessarily entail greater deformity, both in the matter of shortening 
and lateral deviation. A certain proportion of these, as well as of other 
compound and comminuted and complicated fractures, demand, for the 
purpose of obtaining the best possible results, a course of treatment 
having in view the control of the inflammatory action as the primary 
consideration, and the relief of the deformity by lateral supports and by 
extension as the secondary consideration; although perhaps in most 
cases both are to be regarded as necessary indications of treatment. We 
do not of course include in this statement those cases which demand 
immediate amputation. 

Simple, green-stick fractures, denticulated fractures, and most trans- 
verse fractures do not become displaced in the direction of the axes of 
the bones in which they occur, and may generally be made to unite 
without shortening or deformity. They unite also very speedily. 

Fractures occurring in infancy and childhood unite more quickly than 
fractures occurring in adult life; more speedily in the robust than in the 
feeble: and there are certain special conditions, as we have already 
stated in the chapter on delayed union, which tend to retard bony union. 

Fractures of the upper extremities unite in general more speedily than 
fractures of the lower extremities. The smaller bones unite more rapidly 
than the larger bones. In the case of the bones of the face and jaws, and 
of the clavicle, union is especially rapid. This is probably true also of 
the ribs; and this notwithstanding the fact that in the case of most of 
these bones we encounter peculiar and often insurmountable difficulty in 
securing absolute quiet during the treatment. 



54 GENERAL PROGNOSIS. 

Fractures at or near the extremities of certain long bones are less 
liable to displacement, and therefore unite with less shortening and de- 
formity than most fractures of the shaft. They unite also more quickly. 
This is true especially of fractures of the surgical neck of the humerus, 
when the fragments remain in place, of fractures of the lower end of the 
radius, of extracapsular fractures of the neck of the femur, of fractures 
of the lower end of the femur and of the upper end of the tibia. But 
some of these fractures are liable to be complicated with injuries to the 
joints, and to either endanger life or entail a partial or permanent anchy- 
losis. Anchylosis is less liable to result, however, in fractures of the neck 
of the humerus, and in extracapsular fractures of the neck of the femur, 
than in fractures of the lower end of the femur, of the lower end of the 
tibia, and of the lower end of the humerus and of the radius. 

Fractures which actually involve the joints are in general much more 
dangerous to life than other fractures. This statement, however, does 
not include intracapsular fractures of the neck of the femur, and is most 
especially applicable to fractures involving the knee-joint. If old people 
pretty often die not long after receiving intracapsular fractures of the 
neck of the femur, the death is seldom due to the fracture, but rather to 
the shock received and the prolonged confinement and recumbency which 
is perhaps necessitated. In this last-named fracture, the union, if it 
takes place at all, is almost invariably fibrous, and the limb usually 
shortens very much. 

When the patella, or the acromion process, or the olecranon process, 
is broken, the bond of union is generally fibrous, but if the bond is short, 
this does not materially affect the future usefulness of the limb. In the 
case of the patella, when the fracture is caused by muscular action, as it 
generally is, and it is a simple transverse fracture, the new bond of union 
is almost invariably fibrous. 

Anchylosis, more or less complete, is the result of nearly all fractures. 
This may be temporary or permanent. 

Temporary anchylosis is due, first, to disuse and atrophy of the muscles, 
and to passive contraction of the ligaments about the joints. Second, to 
inflammatory effusions and adhesions among the muscular fibres; between 
adjacent tendons and in the sheaths of tendons; in the capsules of the 
joints and among the ligaments. 

All of the forms of anchylosis above described may, but do not often, 
become permanent. Usually the products of inflammation are removed 
by the natural action of the absorbents in the course of a few months, 
and especially when the natural efforts are aided by friction, passive or 
active motion, or by other appropriate means. Passive contraction of 
ligaments and atrophy of muscles are never overcome except by motion, 
either passive or active. If they are not overcome in some degree within 
a year, they are likely to be permanent, or to require for their relief 
active surgical interference, such as brisement force, or some of the 
graver surgical operations. 

Permanent anchylosis, sometimes the result of what ought to have 
been only temporary anchylosis, is more often due to the presence of 
cicatricial tissue resulting from lesions of the muscles, to actual lesions 
of tendons or of ligaments, to firm intracapsular adhesions, and finally to 



GENERAL PROGNOSIS. 55 

bony deposits in or about the joints, to bony consolidation of the adjacent 
bones, to malposition of fragments, to encroachment of fragments upon 
the joints, and to hypertrophy of fragments. 

Pain, tenderness, and more or less loss of strength in the limbs, lasting 
for months or years, are common as sequelre of these accidents: but 
which phenomena have in general little or no direct relation to the 
previous existence of a fracture, unless they are present as the natural 
results of the deformity which remains. They are quite as likely to be 
entailed upon severe injuries where no fracture has occurred. 

After the removal of the splints and bandages the limb is apt to 
become oedematous; a condition which in old and feeble persons may 
continue many months, and the existence of which has been lately 
ascribed to the temporary obliteration of the deeper veins in the region 
of the fracture. This will no doubt furnish a sufficient explanation in a 
certain proportion of cases, and perhaps a partial explanation in all 
cases: but the partial paralysis or loss of tone in the superficial veins, 
and in all the superficial tissues, due to the long-continued pressure of the 
bandages, is probably quite as responsible for these results as the deeper 
seated changes due to the injuries arising directly from the fracture. It 
is generally found to exist in a pretty exact ratio with the long continu- 
ance and tightness of the bandages. 

Having thus briefly stated the general prognosis in fractures, it seems 
necessary to call attention to certain statements recently made by a gen- 
tleman who enjoys a reputation, and who occupies a position as a public 
teacher of surgery in one ot our most flourishing medical colleges, and 
which statements are widely at variance with my own views as above 
given, and with the published views of all other surgeons who have given 
sufficient attention to the subject to entitle their opinions to respect. 

Dr. Sayre. of this city, in a Report on Fractures made to the Ameri- 
can Medical Association in 1874, 1 says: 

" Fractures of the long bones require that extension and counter-ex- 
tension, under the influence of chloroform, or other anaesthetic, if neces- 
sary, should be made in a. proper direction, until perfect accuracy of 
adjustment is obtained, and after this, retention and fixation in this 
normal condition until consolidation. [The Italics are Dr. Sayre's.] 

"By accuracy of adjustment, I mean the perfectly normal condition 
of the bone as to length and position. When the extension and counter- 
extension have been properly made, the muscles and other tissues sur- 
rounding the bones will necessarily and positively force the fractured 
extremities into their natural position, as above described, unless some 
foreign body, as a shred of muscle or connective tissue, has got between 
the fragments." 

Dr. Sayre closes his remarks, which are comprised in less than four 
pages, by presenting, as a "supplement," a " Table of the Fractures 
treated in Bellevue Hospital in the year 1873, which has been com- 
piled from the hospital wards by Dr. Van Wagenen, late House Surgeon 
to Bellevue Hospital " (actually from April 1, 187:2, to April 1. L873). 

Report on Fractures, by Louis A. Sayre, M.I) , Prof, of Orthopaedic and Clinical 
Surgery. Bellevue Hospital Med. Col., Burgeon to Bellevue Hospital, ''to. Transac- 
tions Amer. Med. Asa • .. 1874, p. 801 et seq. 



56 GENERAL PROGNOSIS. 

The table referred to, however, does not comprise all the cases treated 
in Bellevue during that year, but only those treated with the plaster- 
of-Paris dressing, and of this class only those which Dr. Van Wagenen 
found "thoroughly" recorded; so at least the author informs us. 

There is no danger, perhaps, that such extraordinary statements will 
affect the opinions of experienced surgeons in any part of the world, 
but they will be read probably by many inexperienced surgeons, and 
may with them have the weight of authority ; and, indeed, they have 
already been quoted by the author of a treatise on Civil Malpractice, 
intended as a guide to jurists, and which is widely read by lawyers and 
medical men. 1 The author has, however, modified the force of the 
authority by expressing his belief that while such results might be 
possible with Dr. Sayre, they can hardly be expected from the " ordi- 
nary " surgeon ; but how will it be with Dr. Sayre's peers, nearly all of 
whom, in every part of the world, and with the same appliances used 
by him, declare their inability to make all long bones unite without 
shortening, and who, indeed, affirm that with them union without some 
shortening is the exception, and not the rule, a doctrine against which 
Dr. Sayre entered his earnest protest, before the American Medical 
Association, both at Detroit and Buffalo. 

Our personal interests, as well as the interests of science and humanity, 
demand that we shall know positively whether shortening can always be 
avoided, or even made the exception rather than the rule ; but we need 
something more than mere assertion, however notorious may be the 
author's reputation for accuracy of observation and for truthfulness of 
statement. 

Having myself, with the assistance of my staff, very thoroughly 
searched the records of Bellevue Hospital from time to time, I am 
prepared to say that the evidence we need is not to be found there, nor 
has it been supplied in such cases treated by my distinguished colleague 
as have come under my personal observation, yet having for a number of 
years served alternately in the same wards at Bellevue with himself, my 
opportunities of observing the results of his practice have not been few. 
That I have not generally adopted his practice, also will be accepted, I 
trust, as evidence that I did not consider his results satisfactory, and 
that although my declared ability to perform was much below his. 

So far as we know, the only proof ever offered is found in the tables 
which Dr. Sayre presented as a supplement to his brief paper, showing 
the results in certain cases at Bellevue by the plaster- of-Paris treatment, 
which is known to be at present Dr. Sayre's favorite method. Pre- 
sumably a portion of them are his own, although it is not so stated. At 
any rate, they all had the benefit of that "skilled assistance" and "the 
mechanical paraphernalia pertaining to a hospital" which Dr. McClel- 
land regarded as the necessary condition of Dr. Sayre's remarkable 
success, or of the success which in his belief all surgeons ought to attain. 

Some of the cases, Dr. Van Wagenen informs us, were imperfectly 
recorded, and all such were rejected. It will be found, however, on 

1 Civil Malpractice, a treatise on Surgical Jurisprudence, etc., by Milo A. McClel- 
land. M.I). New York, Hurd 6: Houghton, 1877. 



GENERAL PROGNOSIS. 57 

examination of the tables, that not a few have been retained in which 
the results are not exactly known. We are not informed that Dr. Sayre 
himself measured any of the limbs, or personally noted the amount of 
resulting deformity. Accepting, however, the testimony as it stands, 
and confining our analysis to simple fractures, we find twenty-two simple 
fractures of the shaft of the femur. Of these, only three have united 
without shortening ; the shortening being given in the nineteen cases as 
ranging from one-fourth of an inch to two inches. In one it is one inch 
and an eighth, in one an inch and a quarter, and in a third it is two 
inches. Of those which are not shortened, one was seven years old, one 
was seventeen years old (and in this latter the fragments were never 
displaced, there being observed only crepitus when the patient was 
admitted, without shortening or deformity), the third was in a man 
twenty-three years old. A reference to the tables constructed from my 
own personal experience by other modes of treatment, which will be 
found in the chapter on ''Fractures of the Femur," will show that these 
results do not compare favorably with my own in the matter of length. 
In one of Dr. Sayre's cases the femur is bowed out somewhat at the 
seat of fracture. In one the fracture did not unite, and no explanation 
is offered of this fact except that the plaster-of-Paris splint became loose. 

Two simple, intracapsular fractures of the neck of the femur are re- 
corded : also two extracapsular, and one trochanteric fracture. These 
are all shortened ; the shortening ranging from one-quarter of an inch 
to one inch. 

The remaining fractures of long bones included in these tables are 
fractures of the tibia and fibula, of the humerus, and of the radius and 
ulna. Rejecting the compound, complicated, and comminuted fractures, 
as belonging to an exceptional class, although Dr. Sayre has not spoken 
of them as exceptional; and confining our attention only to simple 
fractures, in which it will be admitted the best results ought to be ob- 
tained; and rejecting all fractures of the forearm and leg in which only 
one bone was broken, and in which shortening is never expected to take 
place ; there remain sixteen simple fractures of both bones of the leg, 
seven simple fractures of the humerus, and two of both bones of the 
forearm. In only one of this whole number (twenty-five cases) is there 
any reference to the question of shortening, and in this one case the 
limb is said to be shortened five-eighths of an inch. Of the remainder 
it is occasionally said that there is no record, or it is incomplete, although 
we are informed in the caption of the tables that all such cases were 
rejected. 

What are we to infer from this almost universal omission of the relative 
length of the two limbs in these latter cases? In the table of fractures 
of the femur it is never omitted : but simple fractures of the humerus, of 
both bones of the forearm and leg are recorded variously as "cured," 
'•union and position good," or "union and position perfect;" but thai 
these phrases are not used to imply a restoration of the limbs to their 
normal length, is evident from the facf that in certain other complicated 
fractures the ''union and position" are said to be "good" or "perfect," 
and they are nevertheless marked as "shortened." 

The truth is, probably, the limbs were never measured. If they 



58 GENERAL PROGNOSIS. 

were, these omissions cannot be excused, inasmuch as they render the 
tables valueless for the purpose for which they were prepared and pre- 
sented to the Association. So far as the question of angular deformity 
is concerned, its existence is mentioned sufficiently often to indicate no 
improvement upon the practice of surgeons generally, although, as is well 
known, this species of deformity, especially that which is caused by a 
simple overlapping of the fragments, Avhile the general line of the axis 
of the limb is perfect, is seldom seen very distinctly until a long time 
after the treatment is suspended, and the patient has been dismissed 
from the hospital, and therefore, if it existed, it may not have been 
observed when the records were made. In short, these tables are not 
what they might be thought to be, reliable testimony as to results; and 
even as they stand they do not in any measure sustain the statements 
made by Dr. Sayre, that even simple fractures of the short or long 
bones can always be made to unite without shortening: but, we repeat, 
Dr. Sayre makes no such exceptions, in favor of fractures of the neck 
of *the femur, or of comminuted fractures and compound or complicated 
fractures, provided they do not demand amputation, or there is not some 
foreign body interposed between the ends of the fragments. 

Jan. 4, 1875, Henry Balchemeider, set. 37, was admitted to Ward 14, 
. Bellevue, with a simple fracture of the left femur near its middle. 
Five hours after the receipt of the injury two of our most experienced 
house surgeons put the patient under ether, and with pulleys made 
extension until, as they declared, the limbs were of the same length. 
They then applied the plaster-of-Paris splint. The patient was on 
crutches in a few days. Five weeks and three days from date of the 
dressing, the man was brought before the class in my surgical clinic at 
Bellevue, in presence of Dr. Sayre and the late Dr. Krakowizer. The 
splints being removed, the limb was found united with a slight outward 
bend at the seat of fracture, and the knee-joint very stiff. On measure- 
ment I found it shortened one inch. Dr. Krakowizer and others made it 
the same, but Dr. Sayre thought it was a "little lengthened." It will 
not be difficult to understand, from the results of measurement in this 
case, that Dr. Sayre would meet with examples of perfect restoration 
of the bone often er than Dr. Krakowizer or myself. 

In the previous editions of this book, I have, in connection especially 
with fractures of the femur, alluded to the difficulty of making accurate 
measurements of limbs, so as to determine the amount of shortening; 
and I have also mentioned the fact that, as long ago as 1862 or 1863, 
Dr. Cory don La Ford, of Brooklyn, N. Y., had demonstrated by meas- 
urement upon the skeleton that occasionally the malleoli of the leg were 
of unequal length in the opposite limbs. I have now to call attention to 
the fact that a certain amount of asymmetry in all the long bones of the 
extremities is the rule and not the exception. The observations which 
led to these conclusions were first made upon the lower extremities by 
Dr. W. C. Cox, of Philadelphia, while he was a student of the Pennsyl- 
vania Hospital. They were subsequently confirmed, and the examination 
then extended to the upper extremities, by Dr. Wm. Hunt, of Philadelphia, 
by Prof. J. S. Wight, of Brooklyn, by myself and others, Prof. Wight 






GENERAL PROGNOSIS. 59 

having especially studied the whole subject. 1 In 1879, Dr. J. Garson, 2 of 
London, published the results of the measurement of seventy skeletons, 
and in a later reference to these observations he says: "The lower 
limbs were equal in length in only seven instances, or in ten per cent. ; 
in twenty-five instances, or 35.8 per cent., the right limb was longer than 
the left, while in thirty-eight instances, or 54.3 per cent., the left limb 
was longer than the right. The left leg I found not only to be more 
frequently longer than the right, but the difference in length between the 
two limbs is greater on an average when the left is the longer. 
Inequality in length is not confined to any particular age, sex, or race, 
but seems to be universal in all respects. My observations corroborated 
those of several American surgeons made on the living subject." Meas- 
urements of fifty skeletons showed a like asymmetry in all the long bones, 
but in the case of the arms the right is most often the longest. The 
conclusions reached by all have been nearly identical, namely, that 
throughout the long bones of both extremities there existed usually 
a certain amount of asymmetry in regard to length. Ordinarily the dif- 
ference is inconsiderable, ranging from one-eighth of an inch to one-half, 
but sometimes much exceeding this without having been noticed by the 
patient or by his friends. In the case of the lower extremities the left is 
more often the longer than the right. 

These conclusions by no means render the measurements of limbs 
valueless, although they place a serious obstacle in the way of our attain- 
ing that precision which is desirable when we seek to determine the 
relative value of different plans of treatment in preventing shortening. 
Unfortunately. I may say, we have not yet devised a method of exten- 
sion so effective that our ignorance of the original normal differences 
causes any embarrassment. The fact is, and always has been, that 
measurement of the limb in which a long adult bone has been broken 
obliquely and has united, shows, in a large majority of cases, that it is 
shorter than the other; and the frequency of this occurrence is evidence 
that in many cases it becomes the shortest limb, although it was origi- 
nally the longest, and it leaves a possible question whether those few cases 
which we have regarded as perfect results, because the opposite limbs 
were after consolidation of the same length, were not then symmetrical 
solely in consequence of the shortening; and we may consider it probable 
that in other cases the actual shortening is much more than is indi- 
cated by the measurements. Nevertheless the unpleasant fact remains, 
and is rendered only the more conspicuous, that oblique fractures of the 
long bones in the adult generally shorten, inasmuch as we find in 
nearly all cases the broken limb the shortest. When we have found 
an apparatus or a mode of dressing which will make a broken limb as 
long as or longer than the other as often as it is found to be normally, 
then we may lay aside the tape and line, for it will be of no further use; 
practically, also, our labors will be ended, for shortenings no greater 

1 Philadelphia Medical Times, Jan. 16, 1875. Amor. Journ. Mod. Sci., April, lS7-">. 
Archives of Clinical SuTgery, Feb. 1877. Hospital Gazette, April 12, 1879. 
- Garson, Journal of Anatomy and Physiology, vol. xiii. p. 502, 1879. Nature, 

Jan. 26, 1884. 



60 GENEKAL PROGNOSIS. 

than normal deviations occasion no maiming or halting, and are of no 
consequence. 

A distinguished English surgeon has recently said that he has given 
up measuring broken thighs, — because of the uncertainty of measurements, 
I infer. This is a return to the practice of surgeons for many centuries 
preceding the present century. Until within the last thirty years no 
systematic attempt was ever made to determine the exact length of limbs 
after fractures. Tables were given from various hospitals at home and 
abroad, declaring how many were cured, with some slight notices of de- 
formity, but with no reference to the amount of shortening. It was this 
which led Mr. Johnson, the famous editor of the London Medico-Chi- 
rurgical Review, to say of Mr. Radley's results, that he would " like to 
know something about the length of the cured limb, and a few other 
matters of that sort." 

In the April number of the Buffalo Medical Journal for 1849, I 
published the results of a careful measurement of 136 cases of fracture 
of the long bones, treated in various ways by different surgeons. So far 
as I know, this was the first publication of the kind ever made. In 1853, 
Dr. John Boardman published from my notes additional cases, making 
461 in all. In my report on deformities made to the American Medical 
Association in 1855-6-7, additional cases were reported at length, 
making a total of 605. 

The results of these observations were startling, both to the author 
and the public generally, and led, I have reason to believe, to that wide- 
spread interest which has since manifested itself in this country, as to 
the causes of the apparent defects in this department of surgery, and to 
serious inquiry as to the remedy. Surgeons everywhere were stimulated 
to a new exercise of their ingenuity and skill. Then followed speedily 
the abandonment of all the double inclined planes for fractures of the 
femur, and also of the long splints of Desault, Boyer, Liston, Hagedorn, 
Gibson, Physick, and others, which, while they gave better results so far 
as the form of the limb was concerned, made little or no improvement in 
the matter of length. I do not hesitate to say that within these last thirty 
years, through the more intelligent efforts and correctly applied genius 
of surgeons, the proper treatment of fractures has made more progress 
than it had in all the centuries preceding ; and especially is this true of 
fractures of the femur, where the defects were most apparent, and the 
remedies were most needed. 

Shall we cease these efforts now, when the attainment of practical per- 
fection is almost within sight ? So far as the lower extremities are con- 
cerned, with the present appliances, lateral obliquity, or deformity from, 
this cause, in the case of simple fractures, is, according to my personal 
experience, no longer necessary ; while the average length of the limbs 
is greatly increased. We shall have abandoned the further advancement 
of this branch of science when we cease to measure limbs. 

As to the mode of measuring limbs, I shall speak in connection with 
particular fractures. 

I think it proper to mention venous and fatty embolisms in connection 
with prognosis in fractures, since modern pathological investigations have 






GENERAL TREATMENT OF FRACTURES. 61 

established their occasional connection as sequences, if not as conse- 
quences. 

Virchow, in 1846. was the first to call attention to an example of 
pulmonary embolism due to the presence of a venous clot and consequent 
upon a fracture. Since then, similar examples have been reported by 
other surgeons; the accidents having taken place usually at periods 
varying from two to six or seven weeks after the fracture occurred, and 
being due. as is believed, to the displacement of a clot from a vein in the 
vicinity of the fracture, whose channel had been temporarily closed by 
inflammation and pressure. 

The presence of a pulmonary venous embolism in the lungs may be 
recognized by the sudden occurrence of pain, cough, and dyspnoea, ac- 
companied, perhaps, with bloody expectoration, and the usual physical 
signs of localized congestion or consolidation. In some cases, the symp- 
toms are more urgent, and the patient dies in a few minutes. 

In 1864, Flournoy reported a death from fatty embolism, consequent 
upon a fracture of the leg, death having occurred thirty-six hours after. 
Since then, Busch, Wagner, Czerny, and others have reported similar 
examples. The accident is supposed to be due to the absorption into the 
venous and capillary circulation of the crushed fat globules contained in 
the marrow at or near the point of fracture. The symptoms are said to 
resemble those of shock and of traumatic and alcoholic delirium ; but an 
interval always exists between the occurrence of the accident and the 
accession of the symptomatic phenomena, which latter are by no means 
uniform, the most reliable signs being referable to pulmonary and cardiac 
obstructions. The breathing becomes suddenly difficult or labored ; the 
pulse becomes feeble and rapid, the countenance pale or cyanosed, and 
delirium, followed by coma, terminates speedily in death. It is affirmed 
also, that in other cases, where the fatty embolisms are less extensively 
distributed, the symptoms, although presenting the same general type, 
are less urgent, and may terminate in recovery. 

It is gratifying to know that both of these forms of embolism, as 
sequences of a fracture, are probably exceedingly rare, and that some 
excellent pathologists have even denied that any relation whavever has 
been shown to exist between the presence of the oil-cells in the blood- 
vessels and capillaries and the symptoms which have been attributed to 
them. 



CHAPTER YI. 

GENERAL TREATMENT OF FRACTURES. 

All that has been said in relation to the propriety of handling a 
broken limb gently, when the surgeon is examining the position and 
character of the fracture, is equally applicable to the lifting and trans- 
porting of the patient to his bed, to the removal of the clothing, and 
to the general management of the limb before it is dressed. Etude or 



62 GENERAL TREATMENT OF FRACTURES. 

awkward manipulations, by which needless pain is inflicted, are not 
simply acts of wanton cruelty, but they are sources, and I think I may 
say frequent sources, of inflammation, suppuration, and gangrene. Here, 
as in all the subsequent handlings, everything should be done slowly, 
thoughtfully, and systematically. Yet it is difficult to state the precise 
manner in which the surgeon ought to proceed. Much will depend upon 
the circumstances of the case, something upon one's natural tact, and 
upon the amount of experience, but more, I think, upon natural kind- 
ness o\' heart, and social education. The man of refinement and sensi- 
bility will know instinctively how to proceed, and needs no instruction. 
They who lack these qualities can never learn, and it would be quite 
useless to undertake to teach them. I sincerely wish such men as these 
latter would find some more suitable employment than the practice of a 
humane art. 

Nearly all fractures present three principal indications of treatment, 
namely : to restore the fragments to place as completely as possible ; to 
maintain them in place : and to prevent or to control inflammation, spasms. 
and other accidents. 

It ought to be regarded as a rule, liable only to rare exceptions, that 
broken bones should be restored to place, or to the position in which we 
hope to maintain them, as soon as possible after the occurrence of the 
accident. If the patient is seen within the first few hours, or before 
much swelling has taken place. Ave scarcely know the circumstances which 
would warrant an omission to adjust the fragments either end to end or 
side by side, as the one or the other might be found to be practicable. 
We have before sufficiently explained the general impossibility of again 
restoring to place, end to end, and fibre to fibre, fragments which have 
been made to override. We are therefore in no danger of being under- 
stood to say that bones should in all cases be immediately k * set."' in the 
popular sense of this term. They ought to be "set," no doubt, if this 
can be accomplished through the application of a prudent amount of 
force ; but if they cannot be thus placed end to end, they may at least 
be laid in such a manner side by side as to restore, in some measure, the 
natural axis of the limb, and prevent the points of the bone from pressing 
unnecessarily into the flesh. 

Experience has. indeed furnished us with four or five very good reasons 
why broken bones should be reduced as soon as possible. When the 
injury is recent, the muscles offer less resistance : their resistance being 
increased after a time not only by the reaction which ensues upon the 
shock, but also by actual adhesion between their fibres : effusions distend 
both the muscles and the skin, and compel the limb to shorten ; the 
constant goading of the flesh by the sharp points of the broken bones 
increases the muscular contractions : the patient will submit readily to 
manipulation and extension at first, but alter the lapse of a few days it 
is very seldom that he will permit the limb to be in any manner dis- 
turbed, even if he is assured that his refusal entails upon him a great 
deformity. If it is true that no callus or bony structure is deposited 
earlier than the seventh or tenth day. it is also true that the renewed 
attempt to adjust the bones at this period, by chafing and tearing again 
the tissues, reduces the fracture, in some degree, to the same condition 



GENERAL TREATMENT OF FRACTURES. 



63 






in which it was at first, and. consequently, the time which has elapsed, 
or. at least, a portion of it, may be regarded as lost. 

We cannot, therefore, understand the argument by which Bromfield, 
South, and a few other surgeons have persuaded themselves, that reduc- 
tion should never be attempted before the third or fourth day ; nor. 
indeed, do we fully appreciate the refinement which Malgaigne has given 
to this question, in itself so simple. To affirm that we ought not to 
reduce the bones to their original positions during the period of intense 



Fig. 6. 



Fig 





Many-tailed bandage. 

inflammation, or of great swelling, 
or while the muscles are acting- 
spasm odically, is only to affirm 
that w T e may not do what is impos- 
sible ; and the attempt to do which, 
therefore, can only be mischievous ; 
but to authorize their restoration 
to a better position, by such ma- 
nipulation, extension, and lateral 
support as they may comfortably 
bear, is warrantable under any cir- 
cumstances. The practice is not 
only defensible, but imperative, 
and we do not think any really 
sound and practical surgeon ever intended to teach the contrary. We 
say still, if bones can be easily reduced, or the position of the fragments 
improved at any momnnt, or under any circumstances, it ought to be 
done ; and if we fail in accomplishing all that we wish to do in the first 
instance, we must remain incessantly watchful to seize the earliest oppor- 
tunity which presents, to complete the adjustment. No doubt our efforts 
will prove fruitless very much in proportion to the amount of swelling, 
inflammation, or muscular spasm which exists, and also in proportion to 
the time which has elapsed ; but this will not excuse us for omitting to 
do all which the circumstances permit. 

It has been the practice of most surgeons, for a long period to cover 
the broken limb with some i'<>nn of a bandage or roller before applying 
the lateral splints. (This observation was more true when I published 
my first edition than it is now.) 



Application of the " roller " by circular and 
reversed turns. 



64 



GENERAL TREATMENT OF FRACTURES. 



Of these primary dressings there are two principal varieties : first, 
the u roller" or simple bandage, applied to the limb in circular and re- 
versed turns; and second, the "many-tailed bandage," consisting of a 
piece of muslin, or other cloth torn down from each side into a suitable 
number of strips, leaving the centre, which is to be applied to the back 
of the limb, entire. 



Fig. 8. 



Fig. 9. 





Application of the many-tailed bandage. 



Bandage of Scultetus. 



A modification of this latter bandage consists of a number of separate 
strips, so laid upon one another, commencing from above, that each 
strip shall overlap the other by one-third or one-half of its breadth. 
This is called the bandage of Scultetus, and it possesses one advantage 
over the many-tailed bandage just described, especially in the case of 
compound fractures, in the facility with which each separate piece may 
be removed and another substituted. Some surgeons prefer to form the 
bandage of separate strips, and having overlaid them in the manner 
directed, to unite them again into one by running a thread through the 
whole mass along the centre. 

Whichever of these several varieties of strips are employed, the mode 
of applying them is the same. They are folded alternately around the 
limb, being made to overlap and cross upon each other in front, and 
only the last strip or two is fastened with a pin. 

The object proposed in the use of the roller or of the many-tailed 
bandage is twofold ; first, to compress and support the muscles, by which, 



GENERAL TREATMENT OF FRACTURES. 65 

their tendency to contraction is in some measure controlled ; and second, 
to protect the limb against the direct pressure of the side-splints. 

A moment's consideration will convince us that the first of these 
objects is in most cases fully attained by the lateral splints themselves, 
and by the bandages by which they are retained in place; and that the 
second can be as well accomplished by a single fold of cloth, or by the 
compresses, which ought generally, even when the roller is used, to 
underlie the splints. Nevertheless, we should hardly feel authorized to 
reject these primary dressings solely because the splints and compresses 
furnish a convenient substitute, especially since we are compelled to 
admit that they are occasionally useful, unless objections of a more 
serious nature could be brought against them. Unfortunately, this latter 
supposition is actually true. By ligating the limb completely, leaving 
no point of the tegumentary surface to which the pressure is not applied, 
they too often occasion congestion, inflammation, and gangrene. It is 
not until lately that the attention of surgeons has been sufficiently called 
to this subject; but the records of surgery are to-day filled with these 
terrible accidents, formerly attributed to the original injury or to the 
splints themselves, but now understood to be plainly traceable to the too 
common employment of the primary bandage. The roller is by far the 
most dangerous dressing of the two, since it does not yield to the swell- 
ing so readily as the bandage of strips, and it is more objectionable also 
on account of the inconvenience of applying and removing it; but even 
the bandage of strips may be so confined as to produce the same conse- 
quences, as I myself have seen in more than one instance. It is also all 
the more dangerous in the hands of the inexperienced surgeon, because 
he feels a confidence that it will not cause ligation. 

Except in rare cases and for especial reasons, which I shall attempt 
to indicate in their appropriate places, I cannot recommend the employ- 
ment of any kind of bandages next to the skin. 

In order to fulfil the second indication, namely, to maintain the frag- 
ments in place, we employ usually what are called short, side, or coap- 
tation splints, and long or extending splints, or the weight and pulley. 

Side-splints may be constructed from various materials, according to 
the size and circumstances of the limb, or according to the convenience 
of the surgeon ; and as the surgeon cannot be expected to have always 
on hand, at the bedside of the patient, such splints as he might prefer to 
use, it is well for him to understand how to avail himself of such materials 
as may be within his reach, in order that he may make the most of his 
sometimes imperfect resources. 

Lead, sheet-iron, zinc, and other metals have been occasionally em- 
ployed, but especially tin and copper, which possess all of the requisite 
firmness and malleability to allow them to be hammered, and thus 
moulded to the limb. In general, however, they are unnecessarily 
heavy, and demand too much labor to be wrought into shape. I have 
sometimes employed tin splints perforated with large fenestra to diminish 
their weight and increase their flexibility, and found them to answer, in 
certain emergencies, an excellent purpose. The light perforated zinc 
splint-, introduced into the l\ S. Army during the civil war of 18»)l-<'»- _ ). by 
the Sanitary Commission, were found exceedingly useful for field service. 

5 



66 GENERAL TREATMENT OF FRACTURES. 

Iron-wire splints, made from wire-cloth or coarse gauze, were first 
publicly mentioned, so far as I can learn, in a communication to the 
Man [>his Medical Recorder, made by Dr. J. C. Nott, of Mobile ; but they 
have been brought more particularly into notice, and their construction 
perfected, by Louis Bauer. 1 These splints, as modified by Bauer, are 
moulded upon "gypsum or wooden casts," of different sizes, and surrounded 
with a Btout iron-wire frame, in order to give them the requisite degree 
of firmness, and to preserve their forms ; after which they are tinned by 
galvanism, and varnished, to prevent them from becoming rusted. When 
applied, Dr. Bauer recommends that they shall be filled with loose cotton, 
and that they shall be held in place by rollers. It is claimed for these 
splints that they are light, flexible, permeable to air and to the perspira- 
tion, and that they permit the application of cooling lotions without 
impairing their firmness; the last of which is a quality of questionable 
value, since lotions applied to permanent dressings of any kind are only 
warm fomentations, and do not, therefore, in this respect serve the pur- 
pose for which they are intended. They render the skin tender, and 
disposed to vesicate, and they, also, give rise to a sensation of scalding, 
which is sometimes almost intolerable. The water soaks into the bed, 
and in many other ways renders the patients uncomfortable. Lotions 
are only applicable where the dressings are open, loose, and temporary. 

According to Poinsot (note to French edition of this work), the wire- 
gauze splint has been used in the Hospital of St. Andrew, Bordeaux, 
since 1868; a strip of leather being substituted for the stout wire frame 
of Bauer. 

The same objections hold, also, to this as to all other forms of moulded 
metallic, or carved wooden splints, namely, that they seldom exactly fit 
the limb, even when the supply of assorted sizes is complete, and that 
they are not sufficiently flexible to adapt themselves to anything but the 
slightest irregularity of surface. They are not, however, without merit, 
and they deserve at least a qualified commendation in many cases. 

Horn and whalebone may be employed in thin plates, or in the form of 
narrow strips quilted into cloth; but they are expensive, and possess 
no special value except in an emergency. Reeds, the coarse rank grass 
which grows in swamps, flags, willow branches, and unbroken wheat 
straw, may be quilted between two thicknesses of cloth in the same 
manner, and form very excellent temporary splints. I have especially 
found it convenient to use wheat straw in the form of junks. Gathering 
up a bundle of unbroken straws of the size of my arm, I roll them 
snugly in a broad piece of cotton cloth, cut off the projecting ends, and 
then stitch up the cloth neatly. We have thus a splint of considerable 
firmness, and one which is cool and especially adapted to the summer, 
allowing the perspiration to evaporate freely. Straw splints were 
employed sometimes by Ambroise Pare, by J. L. Petit, Larrey, and 
I have seen them in the wards of certain European hospitals, although I 
am unable now to say under whose direction. Mr. Tuffnell, of Dublin, 
has especially recommended them in the form of junks. 2 

1 Nott and Bauer, Buf. Med. Journ., vol. xii., April, 1857. 

2 Tuffnell, New York Journ. Med , March, 1847, p. 264. 



GENERAL TREATMENT OF FRACTURES. 67 

Wooden splints, made of pine, willow, white or linden wood, or of 
some other light and easily wrought timber, are probably of more general 
application, and possess greater intrinsic value than splints constructed 
from any other solid material: but I wish at once, and for all, to dis- 
claim any intention of giving even a qualified approval of any of those 
carved, polished, and generally patented wooden splints, which are manu- 
factured and sold by clever mechanics, and which one may see suspended 
in almost every doctor's office, whether in the city or in the country. 
Constructed with grooves and ridges, and variously inclined planes, for 
the avowed purpose of meeting a multitude of indications, such as to 
protect a condyle, to press between parallel bones, to follow the subsi- 
dence of a muscular swelling, etc., they never meet exactly a single one 
of these indications, whilst they seldom fail to defeat some other indica- 
tion of equal importance. They deceive especially the inexperienced 
surgeon into the belief that he has in the splint itself a provision for all 
these wants, and consequently lead him to neglect those useful precau- 
tions which he would otherwise have adopted. 

If carved wooden splints are employed, they ought to be made especi- 
ally for the case under treatment. But this requires time and some more 
mechanical skill than can always be commanded ; and when accurately 
fitted, it is quite probable that the subsidence or increase of the swelling- 
will, within the next forty-eight hours, render some change in the form 
of the splint necessary, or compel the surgeon to throw it aside. 

I much prefer to use plain, straight strips of wood, of the requisite 
width and length, which may be cut at any moment from a pine shingle 
or a thin piece of board ; but in order that these splints may adapt 
themselves to the inequalities of the. limb, and properly support the 
fragments, they ought to be covered with a muslin sack, open at both , 
ends ; into which, and on the side of the splint which is to be placed 
against the limb, bran, wool, oakum, curled hair, or cotton batting may 
be pressed, until it is made to fit accurately. I generally prefer cotton 
batting. Bran is liable to get displaced, and curled hair does not pack 
firmly enough. When the sack is sufficiently filled, the two ends must 
be stitched up. This mode of constructing the splint is simple and easy 
of accomplishment: the splint can be fitted very accurately; the padding 
never becomes displaced : and when the bandages are applied, they may 
be pinned or sewed to the cover in such a way that they shall not slide 
or loosen. 

If pads are employed separate from the splint — and for this purpose, 
I generally prefer the cotton batting — they ought to be made and 
fitted with the same care, and neatly stitched together at their ends, 
rather than pinned. Cotton batting laid loosely next to the skin, or 
underneath the splints at any point, will not keep its place so well as 
when it is inclosed in covers — it is more liable to get into knots, and it 
has altogether a slovenly appearance. The pads may be stitched to the 
roller, and in this way secured effectually in place, but loose cotton is 
subject to no control. 

When I speak of pads, it must not be understood that 1 intend to 
recommend them for compresses, or for the purpose of pressing fragments 
into place. Nothing could be a greater source of mischief in the dressing 



G8 GENERAL TREATMENT OF FRACTURES. 

iA' a broken limb. I have only directed their employment as a means 
of adaptation, and to protect the skin against the direct pressure of the 
splint. 

\h\ Jacobs, of Dublin, Bays that he has seen an excellent splint made 
from the "fresh hark of a tree, taken oif while the sap is rising." "It 
fits admirably," says Dr. Jacobs, "just like pasteboard soaked in water." 1 
Dr. C. C. Jewett, of the 20th Mass. Vols., recommends for the same 
purpose the bark of the liriodendron, or tulip tree. 

Hemlock-tanned, undressed sole leather, cut into shape and soaked a 
few minutes in water, adapts itself easily to the limb, and is sufficiently 
firm. It is especially applicable to fractures of the larger limbs. At 
Bellevue Hospital it has for several years taken the place of almost all 
other materials, for the construction of movable splints. Oak-tanned 
leather is less flexible than the hemlock -tanned, and does not make so 
good a splint. The specimens selected should be of medium thickness. 
Before applying the splint the edges should be bevelled on the inner 
side, and the corners rounded, and a piece of woollen cloth should be 
interposed between the splint and the skin. The leather will become 
hard within twenty-four hours, and at the next dressing it may be re- 
moved, covered with a sack made of woollen or cotton cloth, and replaced. 
Dr. Ap-M. Vance, assistant at the Hospital for Ruptured and Cripples, 
New York, prefers what is known as "bridle leather," which is more 
plastic than sole leather, hardens as quickly, and becomes as firm. It 
can be made very hard by substituting hot water for cool in soaking the 
leather. 

A splint is also occasionally made of thin calfskin, veneered with 
some light timber, such as linden or white wood, the latter being subse- 
quently split into strips of from half an inch to one 
Fig. 10. inch in width, so as to combine a certain degree of 

flexibility with the requisite firmness. 

The Turks use, according to Sedillot, in a similar 
manner, the "nervures" of palm, laid upon sheep- 
skin, and fastened with wooden thongs; 2 and Pack- 
ard mentions that he has seen narrow slips of some 
light wood glued in the same way upon soft pieces of 
buckskin, and then fastened together with two strips 
of buckskin, which were also glued to the splints. 3 
Wood and leather Common, unpolished pasteboard, cardboard, and the 

splint. stout millboard used by bookbinders, constitute in- 

valuable domestic resorts, since they can generally 
be found in the house of the patient; and if in no other way, pasteboard 
may generally be had at the expense of some paper box or of the loose 
cover of some old book. For small bones, the thinner sheets afford a 
sufficient support; but for large bones the thick binder's board is neces- 
sary- In preparing the latter for use, it ought to be moistened with 
water; but if soaked too much it will separate and fall into pieces, or 
lose its firmness when dry, in consequence of having parted with some of 

1 Jacobs, Now York Journ. Med., March, 1847, p. 265, from Dublin Med. Press. 

2 Amer. Journ. Med. Sci., vol. xxiii., Feb. 1889, p. 481. 

3 Packard's edition of Malgaigne, vol. i. p. 173. 







GENERAL TREATMENT OF FRACTURES. 69 

its paste. This splint inav be applied to the limb without the inter- 
position of anything but a few folds of muslin cloth, or a piece of flannel; 
or we may use instead a single sheet of cotton wadding. It must be 
bound to the limb by the roller whilst it is moist ; and. as it dries speedily, 
it forms a smooth, firm, and reliable splint. 

Felt, made of wool saturated with gum shellac, and pressed into sheets, 
makes an excellent moulding tablet for splints. This may be obtained 
at any hat manufactory. Until recently, they were manufactured, and 
moulded into a great variety of forms, by Dr. David Ahls, at York, 
Pennsylvania. A similar material is now made and sold by J. Peirce. 
of Bristol. Pa. A much cheaper material, however, and which has 
nearly all the qualities of the real felt, may be made from old pieces of 
broadcloth, or from any similar closely woven texture, by saturating it 
thoroughly with gum shellac, the gum being dissolved in alcohol in the 
proportion of one pound of the former to two quarts of the latter. Thus 
prepared, it is to be spread upon both surfaces of the cloth with a com- 
mon paint-brush. When this first coat is well dried by suspending the 
cloth where the air will have free access to both surfaces, a second must 
be spread upon one of the surfaces; and then a third; the cloth being 
allowed to dry after each successive coat. Finally, the sheet is to be 
folded upon itself, so as to bring the most thickly covered surfaces 
together, and pressed with a hot flatiron. If it is necessary to have 
greater strength, more gum may be laid upon the cloth, and it may be 
again folded and pressed. When used, it is to be dipped into boiling 
water or held near the fire until it becomes flexible. Shellac cloth 
hardens very rapidly in cooling, and demands, therefore, some quickness 
in its application ; but once applied and fitted, it forms a hard but smooth 
splint, well adapted for all the purposes for which it is designed. It is 
well to mention, if one wishes to keep any portion of the solution which 
is not used, that, in order to prevent evaporation, the vessel in which it 
is contained must be closely covered. Boiling water deprives it of a 
portion of its shellac, and it is better to soften it by holding it to the fire. 

Recently, I have found an article, made by I. M. Holly, a manufac- 
turer of hatters' goods, at 77 Greene Street, New York, which is better 
for general use than woollen cloth treated with gum shellac. The fabric 
is lighter, cheaper, and more flexible. It is made of from four to six 
layers of cotton cloth, saturated with gum shellac and smoothly pressed, 
and is sold by the manufacturer at the rate of about two dollars per yard. 
At the present -time it is used more often by myself, than any other 
material for the ordinary purposes of a movable plastic splint, and I think 
is preferred by most of our surgeons. It is light, and, if dipped in 
hot or boiling water for a few moments, it becomes sufficiently flexible to 
adapt itself readily to almost any inequality of surface. Before being 
cut. a paper model should be made from the limb to Berve as a pattern. 
It hardens quickly, but not too quickly for accurate adjustment. 

There has been lately introduced from Boston, Mass., a kind of blanket 

cloth, coated on one side only with shellac, bul it seems unnecessarily 

thick and heavy, and has not much firmness, and is, I think, in all 

:ta much inferior to the cotton cloth shellac material last described. 

The principal objection to all of those forms of splints which contain 



70 GENERAL TREATMENT OF FRACTURES. 

gum shellac is, they harden so rapidly after being made flexible by ex- 
posure to heat, that it is often found difficult to give them an accurate 
mould to the limb. 

It has been objected to the felt splint occasionally, that it is impervious 
to air and moisture, and that it confines the insensible perspiration; but, 
as I never use splints of any kind without underlaying them with com- 
presses, or woollen cloth, which act sufficiently as absorbents, I have 
never been aware of any inconvenience from this source. 

Dr. R. 0. Cowling, of Louisville, Ky., has called attention to the 
value of Manilla paper in the construction of splints. 1 A limited use of 
this material satisfies me that it possesses most of the qualities of a good 
splint. It is cut into strips, stiffened with starch, and applied longitudi- 
nally or spirally, as may be necessary to cover the limb completely and 
smoothly. For the lower extremities six to eight layers are required. 
The material may be obtained at most large paper stores. 

The employment of gutta percha as a coaptation splint was first sug- 
gested and practised by Oxley, of Singapore. For fractures of the thigh, 
and for the large bones generally, I prefer a thickness of about one-sixth 
or one-fifth of an inch ; but for the fingers or toes it need not be more 
than one-sixteenth of an inch in thickness. In its natural state, and at 
the ordinary temperature of the body, it is nearly as hard and as inflex- 
ible as bone; but when immersed in hot water it almost immediately 
softens, and would become too soft to be conveniently handled unless 
soon removed. It can therefore be adapted to any surface, however 
irregular, and its form may be changed as often as may be necessary. 
It does not harden as rapidly as felt, and it possesses, therefore, in this 
respect, an advantage, since it allows the surgeon more time for adjust- 
ment; whilst, on the other hand, it hardens much more rapidly than 
either starch, paste, or dextrine. Ten or twenty minutes is all the time 
usually required for gutta percha to acquire that degree of firmness 
which will prevent it from yielding under the pressure of a bandage. 

To use gutta percha skilfully requires some experience, and I have 
known surgeons to reject it after a single trial ; but by those who have 
acquired the necessary skill it is generally regarded as an invaluable 
resource. 

When constructing from this material a thigh-splint, we should order 
a very large tin pan, or some open, flat tray, in which we may lay the 
splint at full length. If the splint is required to be twelve inches long 
and six inches wide, we must cut it about fourteen inches long by seven 
wide, so as to allow for the contraction which always takes place more or 
less when the hot water is applied. It is then to be laid upon a sheet of 
cotton cloth of more than twice the width of the splint, in order that the 
cloth may envelop it completely when it is folded upon it; and the cloth 
should be enough longer than the splint, to enable us to handle and lift 
it by the two ends without immersing our fingers in the hot water. 
If the gum is not thus covered and supported, it will adhere to the 
vessel, to the fingers, to the surface of the limb, and indeed to whatever 
else it comes in contact with; it may even fall to pieces, or become 

1 American Practitioner, Jan. 1871. 



GENERAL TREATMENT OF FRACTURES. 71 

very much stretched and distorted by its own weight. The cloth cover 
will generally adhere to the splint, and may be permitted to remain upon 
it permanently. 

Place the splint, thus covered, in the basin, and pour on the water 
slowly. As soon as it is sufficiently softened, lay it over the limb, 
moulding it carefully with the hands, or by pressing it against the limb 
with a pillow. If it does not harden rapidly enough, this process may 
be hastened by sponging the outer surface with cold water; and as soon 
as it has acquired sufficient firmness to support itself, it may be removed 
and immersed in a pail of cold water or placed under a hydrant; after 
this, it is to be neatly trimmed and wiped dry, when it is ready for use. 

AY hen gutta percha remains a long time exposed to the air, it gradually 
oxidizes, its color becomes darker, it loses its tenacity and flexibility. 
This may be prevented by keeping it constantly immersed in cold water. 
It may be sufficient to place it in a damp cellar. 

The same objection has been made to gutta percha which is occasion- 
ally made to felt, namely, that it confines the perspiration, but to this 
I have already sufficiently replied. 

There is scarcely any fracture demanding the use of a splint in which 
I have not demonstrated its utility, but it is especially valuable, as I 
shall have occasion to mention again, as an interdental splint in fractures 
of the jaw. and as a moulding tablet in all fractures occurring in the 
vicinity of joints. 

Sheets of gutta percha of any required thickness may be obtained in 
this city of Mr. Bishop, the manufacturer, on Twenty-fifth Street, near 
the East River. One pound will make about four thigh-splints. 

Benjamin Welch, of Lakeville, Conn., has contrived a very ingenious 
application of gutta percha to the purposes of a splint, by veneering a 
thin plate of the gum with equally thin plates of elastic wood. The 
veneering is laid upon both sides, and then it is pressed into form in 
moulds. The elasticity of the wood, together with the plasticity of the 
gum, enables the surgeon to change its form somewhat at pleasure, by 
dipping it into hot water. Its form cannot, however, be changed to any 
great extent, and by frequent immersion in hot water the veneering is 
apt to loosen from the gutta percha. 

The moulding tablet of Alfred Smee, composed of gum-arabic and 
whiting, spread upon cloth, 1 has nothing special to recommend it; any 
more than the cloth splints, hardened with the whites of eggs and flour, 
used by Larrey. 2 Starch and alum, glue, pitch, and various other ma- 
terials of a similar character deserve only to be mentioned as having 
been occasionally employed, but which have never succeeded in securing 
for themselves the confidence of surgeons. 

Immovable or Permanent Dressings. — In 1834, Seutin, of Brussels, 
introduced the use of starch as a means of hardening the bandages; his 
method of using which is essentially as follows: A dry roller is firsl 
applied to the skin, and then smeared with starch ; all of the bony promi- 

1 Amer. Journ. Mod. 8ci. r vol. xxvi. p. 220, May, 1840; from London Lancet, 
Jan. 25. 1840. 

'-' Amer. Journ. Mod. Sci., vol. ii. p. 216, May, 1828; from Journal dee Pn 

vol. iv. 



72 



GENERAL TREATMENT OF FRACTURES. 



Fig. 11. 



nences and irregularities of the limb are filled up or covered with cotton 
batting, charpie, down, etc. ; strips of pasteboard, or of binders' board 
moistened and covered also with starch, are now laid alongside the limb, 

over which again are turned in succession 
one, two, or three layers of the starched 
roller ; the number of rollers and the 
thickness of the pasteboard being propor- 
tioned to the size of the limb or to the 
required strength of the splint. The 
whole is completed by starching the out- 
side of the last bandage. 

This dressing will generally become 
dry within from thirty to forty hours ; 
which process may be expedited by ex- 
posing its sides as much as possible to the 
air, or by the application of artificial heat 
with bags of dry sand, or with hot bricks. 
As a temporary support until the drying 
is completed, some surgeons lay upon each 
side of the limb additional splints, securing 
them in place with tapes. 

As soon as the bandages are dry, they 
are to be cut along the front to a sufficient 
extent to permit of an examination of the 
limb, and then closed with an additional 
roller. For the purpose of opening the 
bandages, both at this period and subse- 
quently, Seutin uses a pair of strong scis- 
sors or pliers, such as are represented in 
Fig. 12. 

On the third or fourth day, or as soon 
as the subsidence of the swelling may render it necessary, the bandages 
should be cut open through their whole extent, the edges pared off and 
brought together again snugly with an additional roller. 




Starch bandages, applied for a 
broken thigh. 



Fig. 12. 




Seutin's pliers. 



In 1837, Velpeau substituted dextrine (" British gum ") ; a kind of glue 
or jelly obtained by the continued action of diluted sulphuric acid upon 
starch at the boiling-point. It is prepared for use by dissolving it in 
alcohol or tincture of camphor, or camphorated brandy, until it has ac- 
quired about the consistence of honey ; at this point hot water should be 



GENERAL TREATMENT OF FRACTURES. 73 

added, reducing its consistence to that of thin treacle, when, after one or 
two minutes' shaking, it is ready for application. According to F. 
d'Arcet. the proportions most favorable to the drying and solidifying of 
the apparatus are, one hundred parts of dextrine, sixty of camphorated 
brandy, and fifty of water. Malgaigne, to whom I am indebted for this 
observation of d'Arcet, says, also, in a note, "As regards dextrine, an 
important point was recently brought practically under my notice, viz., 
that, as sold in the shops, it is often unfit for making an agglutinative 
mixture : it forms lumps with alcohol, as starch does with cold water, 
without cohering ; and twice in succession I have been obliged to change 
the supply at the Hopital Saint Antoine. The dextrine thus deteriorated 
is whiter and less saccharine ; it crepitates more in the fingers ; and on 
pouring a few drops of tincture of iodine into the solution,. there is pro- 
duced a violet tint, indicating the presence of fecula ; while true dextrine, 
treated with iodine, gives a vinous red, or the color of onion-peel." The 
addition of one part of common glue to six of dextrine, renders the splint 
more tough. 

Velpeau soaked his bandages with the dextrine before applying them, 
but. like Seutin, he applied his first roller dry. He used but one band- 
age, which he carried first from below upwards, and then from above 
downwards ; and he rarely thought it necessary to employ the pasteboard 
as a collateral support. 

Tripolith was first introduced by Skenk as a substitute for plaster in 
the preparation of bandages. It is a gray powder, composed of lime, 
silex. and oxide of iron. Lately Langenbeck and other German sur- 
geons, and some of the French surgeons, including M. Poinsot, have 
spoken of it quite enthusiastically. It hardens much more quickly than 
plaster, and is much lighter, in both of which qualities it resembles 
dextrine. 1 But Dr. N. S. Nelson, in his inaugural thesis at Harvard, 
declares that he h'as experimented with it, and that it hardens too quickly ; 
that it is not, as claimed by Langenbeck, impervious to water; that it is 
expensive, and as a splint "untrustworthy." 2 

A mixture composed of equal parts of precipitated chalk and gum- 
arabic, reduced to a proper consistence by boiling water, applied to rollers 
while they are being applied to the limb, forms a firm and light splint. 
It has the advantage also of hardening quickly. 

Startin and Tait, of London, recommend paraffine, which, being thor- 
oughly melted, is cooled a little, to render it more viscid, and then 
rubbed into the meshes of the bandage, during the process of application 
with a paint-brush. 

Morgan, of the Middlesex Hospital, uses the best French glue, dis- 
solved in water, with a little alcohol; while Levis, of Philadelphia, has 
recommended glue mixed witli a small amount of oxide of zinc, the latter 
being added to hasten the process of hardening. 

Silicate of soda, of potassa, or of magnesia, have also been employed 
in the same manner. Of these the silicate of soda is the least expen- 
sive and equally firm, but does not harden as quickly as the silicate of 

1 Berliner Klinische Wocnenschrift, 1880. 

2 Nelson, Annals of Anatomy and Surgery, April, 1882. 



74 



GENERAL TREATMENT OF FRACTURES. 



potash. A saturated solution is prepared, and applied with a brush. 
It forms a light, firm, and neat splint. Wheat-flour paste, if properly 
made, dries about as quickly as the starch, and is equally firm. 

Whatever material is used — whether starch, flour paste, dextrine, 
paraffine, tripolith, solutions of the silicates, glue, gum shellac, or plaster 
of Paris — in the construction of what is now usually termed the " immov- 
able apparatus," or, as Seutin has more lately called it, the "movable 
immovable apparatus" (" niovo-amobile "), in reference to his practice of 
opening it at an early period, it is still the same apparatus in effect, and 
is liable to the same judgment — a judgment which Ave shall find it very 
difficult to declare, since from the day in which this practice was first 
recommended by Seutin, to the present moment, it has been constantly 
experiencing the most extraordinary vicissitudes in the public favor. At 
one time, and by the most experienced surgeons, extolled as a method 
unequalled in its simplicity, efficacy, and safety ; and at another, and by 
surgeons of equal experience, denounced as eminently lacking in all the 
true essentials of an apparatus for broken limbs. These conflicting 
opinions, which it is impossible to reconcile, haye nevertheless some foun- 
dation in truth. The immovable apparatus of whatever materials con- 
structed, is under some circumstances a very simple, safe, and efficient 
dressing, while under other circumstances it is, as we think, eminently 
unsafe and inefficient. Thus, in all of those fractures which are ac- 
companied with such injury to the soft parts as to render subsequent 
inflammation inevitable or probable, this form of dressing exposes to con- 
gestion, strangulation, and gangrene. Whatever its advocates may say 
to the contrary, the simple fact is before us that the number of accidents 
resulting from this practice is out of all proportion with any other yet 

Fig. 13. 




Opening of the apparatus with Seutin's pliers. 

introduced. I myself have met with them in all parts of my own country, 
and the journals abound with records of disasters from this source. 1 Nor is 
it a sufficient reply to this statement that with proper care and prudence 
such accidents may be avoided. We think they could not always be 
avoided. But admitting that they could, it is still undeniable that in 



1 Amer. Journ. Med. Sci., vol. xxv. p. 460, Feb. 1840; also vol. xxxi. p. 212. 
Med. Record, Nov. 1, 1873 ; New York Med. Journ., Aug. 1874, Oct. 1874. 



GENERAL TREATMENT OF FRACTURES. 



75 



Fig. 14. 



certain cases the immovable apparatus demands extraordinary attention ; 
and what is the need of multiplying our cares when already they are 
more than sufficient? Many circumstances, over which he has no con- 
trol, may prevent the surgeon from giving to the limb the full amount of 
attention which is required; and for this reason that apparatus is the 
best which, whilst it answers the indications equally well, exacts the 
least amount of skill and attention on the part of the surgeon. 

Immovable dressings are not only liable to become too tight as the 
swelling augments, but, on the other hand, the surgeon may omit to 
notice that as the swelling has subsided it has become loose. Portions 
of the limb may vesicate, ulcerate, or even slough, without the knowl- 
edge of the surgeon. If, however, the bandages are frequently opened, 
and all the proper precautions are taken, it is possible that these acci- 
dents may also be avoided, but unfortunately experience has shown that 
they have not been avoided in too many instances. 

The cases, then, to which this apparatus seems to be especially adapted, 
are a few examples of transverse or serrated fractures in which the bones 
have not become displaced, and in wdiich little or no swelling is antici- 
pated ; and certain fractures which w T ere originally more complicated, 
but in which- a partial union, and the subsidence of the inflammation 
have reduced them to a more simple condition ; and especially is it 
adapted to cases of delayed union. If now the dressings are applied 
carefully, the bandage being only moderately tight; and a portion of the 
extremity of the limb is left uncovered so that 
we may observe constantly its condition, and at 
proper intervals the apparatus is opened com- 
pletely, in order that we may subject the whole 
limb to a thorough examination: in such cases 
as I have now indicated, and with such precau- 
tions, I admit that the "apparatus immobile" 
constitutes an invaluable surgical appliance, and 
one of which no surgeon can well afford to be 
deprived. 

I have also met with examples of compound 
fractures in which it has seemed proper to apply 
this dressing; and especially when a sufficient 
time had elapsed to render it probable that there 
would be no sudden accession of swelling in the 
limb. In such cases I have preferred generally 
to lay the several turns of the roller directly over 
the suppurating wound in the same manner as if 
no wound existed, and to make a valvular open- 
ing, or window, with the scissors, on tin- follow- 
ing day, in order to allow the matter to escape, 
after which the valve may be laid down and 
stitched, or the piece may be removed entirely, 
and a new piece of bandage drawn closely around 
the limb ;it this point. This may he repeated 
once or twice daily. If an opening is left by the roller, and no 
additional bandage or compress is laid over it, the margins of the wound 




".Apparatus immobile" ap- 
plied over a compound frao- 
ture. 



76 GENERAL TREATMENT OF FRACTURES. 

soon become (Edematous and protrude, making an ugly-looking and ill- 
conditioned sore. 

Plaster-of-Paris moulds, employed occasionally from a very early period, 
and more lately recommended by Hendriksz, Hubenthal, Keyl, and 
Dieffenbach, are not entitled to serious consideration. Heavy stone 
collins. they might serve well enough the purposes of interment, but they 
are wholly unsuited to the purposes of a splint. 

Plaster of Paris has, however, been from a later period employed in 
another form, as an "immovable" dressing. I allude to the so-called 
"plaster-of- Paris bandages," which were first introduced to notice by 
Mathiesen, of Holland, in 1852. In 1854, Pirogoff, surgeon in chief of 
the Russian armies, called attention to the plaster-of-Paris dressing, but 
in a form differing somewhat from that employed by Mathiesen. 

Recurring to the history of the immovable dressing, as briefly narrated 
in the preceding pages, and as more fully recorded in the medical journals 
of the next eighteen or twenty years, we shall find that it had steadily 
declined in public favor, on account of the numerous accidents resulting 
from its use, many of which became the subjects of litigation in the 
American courts ; so that neither the suggestions of Mathiesen in 1852, 
nor the great name and influence of Pirogoff in 1854, nor the advocacy 
of Hunt, of Birmingham, in 1855, nor of Gamgee in 1856, were suffi- 
cient to secure for plaster of Paris the confidence of the profession. The 
period was unfortunate, and surgeons were scarcely willing to give these 
gentlemen a respectful hearing, inasmuch as they at once recognized 
these modes of using plaster of Paris as only modifications of the method 
of Seutin, which, for good reasons, they had just laid aside. 

Since Mathiesen wrote, however, a new generation has arisen ; a gen- 
eration of active, able, and hopeful men ; with no prejudices of experi- 
ence to overcome; to whom the "primary bandage" and Seutin's "ap- 
paratus immobile," convey no apprehensions of danger; and now again, 
following this time the lead of the German surgeons, we find these 
methods in popular favor, both at home and abroad. It will be the part 
of wisdom, while we observe carefully the experience of the present, to 
recall the lessons of the past. 

At Bellevue, during six or seven years, plaster-of-Paris bandages 
were used quite extensively, and, after a careful observation of the 
results in my own wards and in the wards of my colleagues, I find no 
occasion to recall anything I have said of this, as one form of the 
immovable apparatus, in the preceding pages ; the dangers have not been 
overestimated, yet I must say that in fractures of the leg, whether 
simple or compound, when great care is exercised in the management of 
the case, it is in some respects superior to any other form of dressing. 
I shall describe the cases to which it is applicable, more particularly, 
when speaking of these fractures. At the present moment the use of 
plaster of Paris as a dressing for fractures is very little in favor with most 
of the Bellevue surgeons, except in fractures of the tibia and fibula. 1 

1 Treatment of Fractures of the Femur by the Immovable Apparatus, by the 
author. New York Med. Journ., Aug. 1874. A comparison of the results of treat- 
ment of 308 fractures of the thigh at Bellevue Hospital, by Frederick E. Hyde, M.D., 
New York Med. Journ., Oct. 1874. 



GENERAL TREATMENT OF FRACTURES. 77 

The manner of using gypsum bandages, generally preferred at Bellevue 
Hospital, may be thus briefly described. Thin, rather coarse unglazed 
cotton cloth, torn into strips, is laid upon a table and the dry plaster 
rubbed into it until its meshes are full. It is then rolled, and made 
ready for use by immersing it a few minutes in hot water. The limb, 
being held in a proper position, is first inclosed in soft, dry flannel cloth, 
and the rollers are then applied. In most cases two or three thicknesses 
of bandage are found to be sufficient. A more full description of this 
method, known generally as Mathiesen's, will be found in the chapter 
devoted to the consideration of fractures of the femur. 

Another method of using the gypsum bandages, not generally prac- 
tised at Bellevue, is as follows : A dry roller is first applied to the 
limb, or it may be covered with a single piece of cloth of any kind, and 
the irregularities are filled up and protected with cotton-wool, the same 
as we have directed when about to apply the starch bandage. The 
remaining dressings being now at hand and ready for use, we proceed 
to mix the plaster. For this purpose Ave must select the fine, fresh, 
well-dried, white powder. The gray does not solidify well, nor that 
which has been a long time ground, or is moist. The proportions of 
water and plaster usually required are about equal parts by weight. 
For the thigh it may require, perhaps, seven or eight pounds of plaster, 
and for the leg or arm much less. It is probably a better rule to 
direct the gypsum to be added to the water until it is of about the con- 
sistence of cream. The water should be cold and the gypsum thrown 
in not too rapidly, at least not more rapidly than it can be thoroughly 
mixed, otherwise we shall not be able to determine precisely its con- 
sistence. If, while applying the paste, it begins to harden in the bowl, 
Ave must not add more water, as this will again interfere with its final 
solidification upon the limb. It must be thrown aAvay and some fresh 
immediately prepared; or the crystallization may be retarded by throwing 
in a few drops of carpenter's glue, or a little starch, dextrine, or glycerine. 
The solidification may be hastened by adding a little salt to the water. 
When the plaster is good, and it is properly mixed, Ave may allow 
ourselves from five to eight minutes in the application. A large paint- 
brush is the most convenient thing for spreading it, but the hands Avill do 
very Avell in an emergency. 

Everything being ready, the limb is to be seized by assistants at both 
of its extremities and held in a position of steady extension until the 
dressing is completed, and for several minutes longer, or until the plaster 
is hard. The surgeon then .proceeds to lay a long piece of linen — old 
Back will answer as well as any — folded three or four times, and saturated 
Avith the paste, parallel to the two sides of the limb, around which are to 
be immediately placed, horizontally and at several points, short and wide 
Btrips of the same material. These latter are intended to increase the 
strength of the apparatus, and to bind on the side strips. Finally, 
the whole may be painted with the solution. It is very well, however, 
not to cover the front of the limb, or a narrow strip somewhere in the line 
of the axis of the limb, with tin- plaster, as this will not diminish 
materially its strength, and it will enable the Burgeon to open it more 
easily with the scissors. Pirogoff accomplishes the same purpose by 



78 



GENERAL TREATMENT OF FRACTURES. 



laying a piece of narrow tape, soaked in oil, along the line through which 
he wishes to make the section of the splint. 1 

Prof. James L. Little, of New York, makes his plaster splints of two 
or three thicknesses of muslin, or of canton flannel, which, being satur- 
ated with fluid plaster, are laid upon the limb previously shaven and 
oiled, and secured in place with a roller. He advises that the roller shall 
be removed as soon as the plaster is set and a fresh one applied, which 
can afterwards be easily removed. 2 

Some surgeons prefer to construct the plaster splint in the following 
manner: Two pieces of flannel are laid one upon the other, and being 
stitched by a straight seam along the centre, the inner layer is carefully 
folded around the limb, and made fast by a needle and thread. Fluid 
plaster is now spread over the outer surface of the inner layer, and the 
inner surface of the outer layer, when the two are brought in contact 
upon the limb, and the whole secured by a roller. After the splint 
is thoroughly dry it may be cut in front and opened like the cover of a 
book. Hence it has been called the "book-back" method. It is also 
known as the Bavarian. 

There are other modifications of the methods of using plaster of Paris, 
which will be more appropriately described in connection with special 
fractures. 

Drs. Wm. A. Byrd, Frank Green, and others have devised simple 
machines for the purpose of filling the tissue of the cloth with powdered 
gypsum while it is being rolled. 3 Such an apparatus might be very 
useful in an hospital, as a means of saving time, but it is scarcely needed 
in private practice. 

In removing the plaster we generally employ a shoemaker's knife, 
softening the plaster as we proceed with a sponge dipped in hot water. 



Fig. 15 







Von Brun's plaster-cutter. 

As cutting pliers for this purpose, no instrument has been found suf- 
ficiently powerful except that introduced by Dr. Victor von Brun, of 
Tubingen. 

1 Weber on Plaster-of-Paris Bandage, Xew York Journ. Med., May, 1856, p. 341. 
1 On the Use of Plaster of Paris in the Treatment of Fractures, by James L. Little, 
Surgeon to St. Luke's Hospital, etc., Med. Record, Nov. 1, 1873. 
; Med. Record, Oct. 13, 1877, p. 655. 



GENERAL TREATMENT OF FRACTURES. 79 

M. J. Lucas Championniere has recently devised an instrument for the 
same purpose, which Poinsot, of Bordeaux, considers superior to any yet 
invented. 

Professor B. W. Dudley, of Lexington, Ky., one of the most successful 
surgeons in this country, but especially distinguished as a lithotomist, for 
many years employed in the treatment of fractures nothing but a roller, 
regarding both side-splints and extending apparatus as not only useless, 
but absolutely pernicious. 1 This practice, which seems to have originated 
with Radley. of England, has not found, hitherto, in this country or 
elsewhere, many imitators. 

Still more unscientific and irrational was the practice of Jobert, of 
Paris, who employed neither side-splints nor bandages, but only exten- 
sion, in the treatment of all, or of nearly all fractures of the long bones. 
The side or coaptation splints bring the fragments into more complete 
apposition, and secure a more prompt and certain union. They ought, 
therefore, never be omitted, unless the condition of the limb precludes 
their application. 

As to the question of permanent extension in fractures, and the means 
by which it may be most effectually accomplished, nothing need be said 
at this time, inasmuch as it relates only to the fractures of certain bones, 
and to certain forms of fractures ; we must therefore refer its considera- 
tion to those chapters which treat of individual bones. 

In the treatment of CQinminuted fractures, no pains ought to % be spared 
to bring the fragments as nearly as possible into apposition; and if there 
exists at the same time an external wound, and the fragments are small 
and loose, they ought to be removed carefully. Nor, indeed, should we 
be deterred from the attempt to remove them by finding chat they are 
somewhat adherent, if still they are very easily moved about with the 
finger. 

In compound fractures, not unfrequently the end of one of the frag- 
ments protrudes from the wound, and its reduction may be attended with 
considerable difficulty. My practice is usually in such cases to attempt 
the reduction first, by simple extension and counter-extension ; but if 
this fails, a finger is introduced into the wound, and an attempt is made 
to stretch the skin over the sharp point of bone; or a spatula is used, 
formed from a piece of wood, or of any suitable piece of metal which 
may be at hand ; finally, but not until all other expedients have failed, 
the wound is enlarged sufficiently to insure its return. Anaesthetics 
may be employed, also, to facilitate the reduction. 

There are some cases, however, in which the surgeon may feel justified 
in sawing off the projecting end; as when the periosteum is completely 
torn from it by its having penetrated a boot, or even sometimes when its 
extremity is very sharp, and there is reason to suppose that it would 
prick and irritate the tissues. In these cases, also, surgeons have pro- 
I to secure the fragments in apposition by metallic ligatures or 
sutures. In a few instances the practice has been attended with success, 
but in most cases the wires have failed utterly of their purpose, and have 
only proved sources of additional irritation. 

1 Dudley, Trans. Amer. Med. Assoc, vol. iii., 1850, p. 349. 



80 GENERAL TREATMENT OF FRACTURES. 

Ruptured arteries, if within reach, ought always to be tied; and if 
arteries situated remote from the surface bleed freely and for along time, 
we may make some effort to find the open mouths in the wound; but in 
this we rarely succeed, nor is it safe generally to trust to a ligature of 
the main branch which supplies the limb. Fortunately, this bleeding, 
although at first profuse, generally ceases in a few hours under the steady 
employment of cold lotions, moderate compression, and rest. If it does 
not, the chances are that the case will call for amputation. 

To ligate the main arterial trunk which supplies the injured limb, as 
suggested by Poinsot, would, in my opinion, expose the life of the patient 
to greater dangers than to amputate the limb. Under such circumstances, 
with the limb bruised and infiltrated with blood, to cut off its main arterial 
supply, would render the occurrence of gangrene almost inevitable. Com- 
pression at the point of lesion and upon the main artery, at the same time, 
as suggested also by Poinsot, would ensure the same result. 1 

The rule generally laid down by surgeons, that we should at once close 
the wound in compound fractures, with sutures and adhesive straps if 
necessary, or with bandages, is far too absolute. This practice will do 
when there is no great contusion or extravasation of blood; but if blood 
is flowing, it is much better to leave the wound open, so as to permit it 
to escape freely ; and if the severity of the injury warrants the supposi- 
tion that much inflammation is to ensue, the danger of gangrene is 
greatly lessened by thus allowing the opening to remain as a channel of 
exit for the inflammatory effusions. 

It has, however, been claimed of late by Mr. Lister, of Edinburgh, 
and by many others who have adopted his practice, that by the use of 
carbolic acid in the manner which will presently be described, we may 
again return safely to the old practice of closing at once all wounds con- 
nected w T ith fractures, without regard to the degree of contusion, lacera- 
tion, or comminution ; indeed, it is affirmed that by the adoption of this 
method of treatment Ave may avoid suppuration and its consequences in 
a very large proportion of cases. It is believed by Mr. Lister that 
suppuration is mainly due to the presence of certain germs which con- 
stantly float in the air, and which carbolic acid is fully able to destroy. 
Every possible precaution is therefore taken to exclude the air, and to 
disinfect that which is unavoidably brought in contact with the 
wound. The interior of the fresh wound is freely washed with a 
solution of one part of carbolic acid to twenty of water ; nor does he 
hesitate to throw this into wounds communicating with joints. The 
fluid being afterwards carefully expressed, the surface of the wound is 
covered first by the "protective," which is a piece of oiled silk coated 
wit!) a thin layer of a mixture composed of one part of dextrine, two of 
powdered starch, and sixteen of a cold solution of carbolic acid ; the 
latter being of the same strength as the solution employed for injecting 
the wound ; or a piece of oiled silk, covered upon one side with shellac 
varnish, is applied. Over this is laid a piece of gauze, soaked in fresh 
carbolic solution, followed by half a dozen layers of the same material, a 
piece of mackintosh cloth, and finally the antiseptically prepared gauze 

1 Poinsot, French edition of this work, p. 55. 



GEXEEAL TREATMENT OF FRACTURES. 81 

roller is applied carefully and lightly. Meanwhile carbolized spray from 
an atomizer is constantly thrown upon the parts until the dressings are 
completed. In certain cases a drainage-tube, treated with carbolic acid 
solution, is left in a depending portion of the wound. All the subsequent 
dressings are to be made with equal care and formality. The knives 
and other instruments employed are to be thoroughly washed in the car- 
bolized solution : also the hands of the surgeon, and whatever else may 
come in contact with the wound. 

The reputation enjoyed by Mr. Lister, and the distinguished names 
reckoned to-day among his disciples, afford a guarantee that, as against 
certain other methods, it ought to have a preference, and that its actual 
claim to a superiority over all other methods is entitled to respectful 
consideration. Nevertheless, while I admit its excellence, I am far from 
being convinced that, in the case of compound fractures or of other 
wounds, it is capable of doing all that is claimed for it. I do not believe 
— indeed, from actual experience I know — that the knee-joint cannot be 
•• freely laid open " under the Lister treatment " with the certainty that 
no danger will follow/' 1 Nor have I seen compound fractures treated 
any more satisfactorily or successfully by this method than by methods 
employed by myself and others. Only very recently a compound frac- 
ture of the leg. in one of our best metropolitan hospitals, was progressing 
rapidly from bad to worse under this plan, the limb becoming more and 
more inflamed and swollen and being threatened with gangrene, when, 
the hot water-dressing being substituted, the inflammation speedily sub- 
sided, and the limb was saved. It is impossible to exclude atmospheric 
germs from wounds which have been long exposed to the air before they 
are placed under antiseptic treatment, and it can easily be shown that 
absolute exclusion of air does not prevent, necessarily, suppuration and 
decomposition in those cases, nor insure against the presence of bacteria. 
That carbolic acid and many other antiseptics do this to some extent is 
true ; but this is all that can be justly claimed for any of the antiseptics ; 
and this is no more than surgeons have understood for a long time. 

In short, if the method of Mr. Lister has any advantages, and it no 
doubt has. these advantages consist in the continuous application of a 
mild stimulating lotion, in the exercise of great care and tenderness in 
the removal and reapplication of the dressings, in the absolute rest im- 
posed, in the occasional use of the drainage-tube, and in the antiseptic 
properties of the carbolic acid, and not, as has been taught by some sur- 
3, exclusively, or even mainly, in the employment of an antiseptic. 

Most wounds, including the wounds caused by fractures, need at the' 
first, and not unfrequently during the whole course of their treatment, 
a certain amount of gentle stimulation, such as dilute carbolic acid is 
capable of causing; and especially is this true since the introduction of 
anaesthetics, which suspend for a time many of the vital forces, and cause 
a delay in the effusion of organizable materials, and in the process of 
repair. Carbolic acid, or any other mild stimulant, hastens the return 
and accelerates the progress of this repair. 

1 Joseph Lister, F.R S. Remarks at the International Med Congress, in Philadel- 
phia, 1870, Transactions, p. 535. 

6 



82 GENERAL TREATMENT OF FRACTURES. 

The really essential things in the successful treatment of compound 
tract hits are, that no additional injury shall be done to the limb by rude 
handling — by thrusting the fingers and instruments unnecessarily into 
the wound — by forcible extraction of slightly detached fragments — by 
violent wrenching and pulling of the limb in order to complete a diag- 
nosis, or to adjust the fragments, or to wholly overcome the shortening 
— by tight bandages or badly adjusted splints; that the sponges and 
other materials applied to the sore shall be free from infectious agents ; 
that the dressings be not disturbed too often, but often enough ; that 
each dressing be made without disturbing the limb, or in any degree in- 
flicting pain upon the patient ; that pent-up matter be timely evacuated, 
but not rudely pushed out by manual pressure. The limb has enough to 
contend with in the original accident, without the added dangers of rough 
handling, or of probing, so generally practised by badly trained nurses, 
and badly trained and reckless surgeons. 

Drainage-tubes are no doubt often useful and even essential ; but they 
, are as capable of doing harm as of doing good. They may be thrust in 
and drawn out from time to time unnecessarily, often causing pain and 
haemorrhage; or they may be allowed to become blocked, and thus ac- 
tually dam up the fluids instead of facilitating their escape. In short, 
in many cases they are wholly unnecessary, and in some injurious. 

To insure absolute rest to the limb some very light but firm splints . 
may be employed to secure immobility, or a pi aster-of -Paris splint, and 
the limb may require to be suspended ; but these are points upon which 
the surgeon must use his own judgment. 

If inflammation threatens the safety of the limb it may be necessary 
to remove all apparatus or splints, and to wrap the limb in sheet-lint 
saturated with water at a temperature of 95° or 100° Fahrenheit ; or if 
gangrene has occurred, or its occurrence is imminent, water at a tem- 
perature of 105° or 110° should be substituted, and this elevated tem- 
perature should be maintained assiduously by constant or very frequent . 
flooding with the hot water. 

There are no circumstances known to me when, according to my later 
experience, it would be proper to apply ice or cold dressings in com- 
pound fractures, unless it be to restrain haemorrhage. 

Bleeding is rarely if ever necessary, and in a large majority of cases 
it would prove injurious by lowering the vital forces, which need to be 
husbanded in view of the requirements of the process of repair, and of the 
probable long and exhaustive confinement. It might even prove speedily 
fatal by adding to the immediate depression. 

Cathartics should also be administered cautiously for the same reason ; 
and because they are liable, and. especially in fractures of the lower ex- 
tremities, to occasion a serious disturbance of the limb. 

Many years since. Dr. J. Rhea Barton introduced into the Pennsyl- 
vania Hospital what has since been called the "bran dressing" for the 
treatment of compound fractures of the leg ; the limb being made to 
repose in a box filled with this material. 1 I have used it very frequently 
in Bellevue and in other hospitals, and can speak of it as possessing many 

1 Amer. Journ. Med. Sci., May, 1835, p. 31 April, 1842, p. 515. 



GENERAL TREATMENT OF FRACTURES. 83 

qualities of excellence, especially as a summer dressing. The peculiar 
mode of using this apparatus I shall describe more minutely when treat- 
ing of fractures of the leg. 

Bones badly united. — Bones which have united with serious deformity 
are occasionally refractured for the purpose of securing a more comely 
or a more serviceable limb. This may be done when the union is recent 
and the callus and adjacent tissues are vascular, with almost an assurance 
of a prompt union. Indeed, if the bone be refractured within four or 
eight weeks after the occurrence of the original fracture, it will in general 
unite more speedily than at first ; and this is especially true in the case 
of children : but if the refracture be delayed much beyond the latter 
period, the chances of prompt reunion become lessened, and after the 
lapse of several months or years the danger that a refracture will result 
in only a fibrous union is considerable. * In the case of an old fracture it 
becomes therefore a question, whether the deformity and maiming are 
sufficient to warrant the surgeon in assuming the risk that it may not 
unite at all. or that it may result in a fibrous union. The cause of this 
delay and uncertainty in the proper union after refracture of bones which 
have been long united, is probably the fact that the bond of union be- 
comes at length harder than the original bone, and although it may 
break as easily as. or even in most cases more easily than, the natural 
bone, it is less vascular, and the tissues adjacent are also perhaps less 
vascular, having undergone certain textural or cicatricial changes in con- 
sequence of the original lesion. 

In deciding this question, then, we will be governed by the degree of 
deformity and maiming, by the time which has elapsed since the union, 
by the general condition of the patient as to constitutional vigor and 
capacity of repair, and especially by the bone, or the portion of the 
bone, which is the seat of the deformity. Refractures of the shafts of 
the humerus and of the femur are less likely to unite by bony callus, 
than refractures of the forearm or leg. If only one bone is broken in 
the forearm or leg, the danger of non-union after refracture is lessened, 
and especially if the lower end of the radius is the part involved. 

There is one popular error in reference to refracture, and indeed the 
error is by no means confined to the laity, namely, that by a refracture 
at any period after four or six weeks we can materially add to the length 
of the limb. The permanent contraction of the muscles which by this 
time has taken place, the presence at an early stage of inflammatory 
effusions, and at a later stage of adhesions, will in most cases effectually 
prevent any considerable elongation of the limb. It may be lengthened 
by being rendered more straight, and in a small degree perhaps by 
actual stretching of the soft tissues, but this is all that can be reasonably 
promised or expected, in a large majority of cases. 

In general, no fear need be entertained that the refracture will en- 
danger the life of the patient, unless the fracture involves a joint. No 
doubt death may have been caused in this way. but a scientifically con- 
ducted refracture is vastly less likely to cause death than the original 
accident. Nor need we generally fear that the bone will break at any 
other point than at the place of the old fracture, provided at least we 
take proper care to make the pressure at the pighl point; we have no 



84 DELAYED AND NON-UNION OF BROKEN BONES. 

need therefore of an osteoclast, such as was devised by Rizzoli, and later 
by Taylor, 1 with which they proposed however only to break limbs which 
were anchylosed in positions which rendered them useless. 

After a careful study of the nine cases of refraeture reported by 
Roberts, of Philadelphia, as having been performed by Levis, liewson, 
Morton, and Hunt, at the Pennsylvania Hospital, I find no occasion to 
modify the preceding statements. In only two of the cases had more 
than ten weeks elapsed between the date of the receipt of the injury and 
the refraeture. 2 Nor do the cases reported by Dupuytren 3 lead one to 
question the soundness of the precept I have attempted to teach. I am 
compel led to say, also, since Dr. Roberts has called attention to Dupuy- 
tren 's table, that it is constructed in a manner very loose and unsatis- 
factory. Of the nine cases which he probably saw, some are not in the 
text, and not all of the cases mentioned in the text are in the table. The 
only refraeture of the femur is reported in the table as in the person of 
a " man " four years old. Nor did Dupuytren see one case in which the 
refraeture was made after ten weeks, the cases in which the period was 
longer — four cases — being obtained from "authentic" sources. 



CHAPTER VII. 

DELAYED UNION, FIBROUS UNION, AND NON-UNION OF 
BROKEN BONES. 4 



i and Varieties. — Most surgical writers concur in the statement 
that non-union of broken bones is an uncommon event. Walker, of 
Oxford, affirms that of not less than one thousand fractures which have 
come under his treatment at some period of the repair, he does not 
recollect more than six or eight instances. According to Lonsdale, not 
more than five or six cases of false joint, excepting those within a cap- 
sule, have occurred out of nearly four thousand fractures treated at the 
Middlesex Hospital. In a table of 367 cases, collected and arranged by 
W. W. Morland, from the books of the Massachusetts General Hospital, 
extending through a period of nineteen years, only one example of false 
joint is recorded ; but as only seventy-four days had elapsed when this 
patient was discharged, it is doubtful whether this might not have proved 
to be a case of delayed union simply. 5 In 946 cases of recent fracture 

1 The Medical Record, April 21, 1877. 

2 J. B. Roberts, Refraeture for the Relief of Deformities after Fracture. Phila- 
delphia, 1878. 

Dupuytren, Injuries and Diseases of Bones, London edition, 1857. 

; I -hall in thia chapter avail myself freely of the labors of George W. Norris, of 

Philadelphia, whose paper, entitled '■ On the Occurrence of Non-union after Frac- 

, its Causes and Treatment," published in the American Journal of the Medical 

es for Jan. 1842, constitutes one of the most complete and reliable monographs 

upon this subject contained in any language. 

Iress on Fractures, by A. L. Pierson, read before the Massachusetts Med. Soc, 
;. 1840. 



DELAYED AND NON-UNION OF BROKEN BOXES. 85 

treated in the Pennsylvania Hospital, between the years 1830 and 
1840, there was no instance of false union. 1 Sir Stephen Haminick, 
Mr. Listen, and Malgaigne affirm also the infrequency of these accidents 
in the eases which have come under their personal treatment. I myself 
have seen a large number of examples of non-union, but in not one of 
my own patients, whether in hospital or private practice, except in 
cases involving joints, has the bone refused finally to unite ; and my 
opinion is that, in proportion to the number of fractures everywhere, 
these cases are very rare, perhaps not in a larger proportion than one in 
five hundred. 

The humerus and femur would appear to be the bones most liable to 
non-union, as shown by Xorris's statistics ; in which forty-eight belonged 
to the humerus, forty-eight to the femur, thirty-three to the leg, nineteen 
to the forearm, and two to the jaw. In my own experience, I have 
found the humerus ununited more often than the femur. 

Berard has shown that in the growth of the long bones the period at 
which the epiphyses are united to the diaphyses depends upon the di- 
rection of the nutritive artery ; for example, " It is found that in the 
humerus, where the direction of this vessel is from above downwards, 
consolidation takes place soonest at its inferior extremity. In the fore- 
arm, the course of the nutrient vessels is from below upwards, and here 
consolidation of the epiphyses is found to occur at the elbow sooner than 
at the wrist. In the inferior members, on the contrary, the epiphyses 
composing the knee are the last which become firm, because in the femur 
the nutritious artery runs upwards, and in the bones of the leg it courses 
from above downwards." A knowledge of these facts led Gueretin to 
inquire into the influence of these arteries upon the consolidation of 
fractures ; and the cases collected by him did indeed seem to show a 
positive relation between the direction of the artery and the union of the 
bone : that is to say, the examples of non-union were chiefly found where 
the fracture had taken place on that side of the nutritious foramen from 
which the artery entered, as if to imply that the non-union was in some 
measure due to the imperfect nutrition of this extremity of the bone. 
In thirty-five cases of non-union analyzed by Gueretin, ten belonged to 
that portion of the bone which was traversed by the artery, and twenty- 
five to the other portion. But an analysis of forty-one cases, made by 
Norris, doe- not seem to confirm this observation of Gueretin, since 
twenty-seven were in the direction of the nutrition- arteries, and only 
fourteen in the opposite portion, or in that which is supposed to be less 
nourished. 

Another observation, made by Curling, that in fractures of the long 
bones the portion below the entrance of the nutrient artery, or on that 
side of the nutrient foramen toward which the blood Hows, being de- 
frauded of its proper supply, is subjected to ;i species of atrophy, pre- 
senting ;i larger medullary canal, with thinner walls, and a spongy tissue 
less dense, also needs confirmation. Malgaigne has not noticed tin- fact 
in any of the specimens contained in the public museums of Paris; and 

1 Norris, loc. cit. 




86 DELAYED AND NON-UNION OF BROKEN BONES. 

I do not know that any other writer has made the question a subject 
of especial inquiry. 

According to Norris, there are four principal kinds of false joint: 

In the first, the bones are united and completely enveloped in a car- 
tilaginous mass or callous tumor, but, in consequence of some retardation 
in the process, bony matter is not deposited, and, as a consequence, it 
wants solidity, the part continuing easily movable. This may be re- 
garded as a proper example of delayed union, as distinguished from 
complete non-union, or false joint. 

In the second, there is entire want of union of any sort between the 
fragments, the ends of which seem to be diminished in size and extremely 
movable beneath the integuments. The limb in these cases is found 
wasted and powerless. 

In the third and most common class, the medullary canal is obliterated 
in both fragments, and the ends are more or less absorbed, rounded, and 

covered, in part or in whole, with a 
FlG - 16 - dense tissue resembling the periosteum. 

A connection also exists between the 
opposing fragments in the form of 
strong ligamentous or fibro-ligamen- 
tous bands, which, if of any length, 
are quite flexible, and allow of considerable motion at the seat of frac- 
ture. 

In the fourth, " a dense capsule without opening of any kind, contain- 
ing a fluid similar to synovia, and resembling closely the complete liga- 
ments, is found." In these cases the points of the bony fragments 
corresponding to each other are rounded, smooth, and polished, in some 
instances eburnated, and in others covered with points or even thin plates 
of cartilage, and a membrane closely resembling the synovial of the 
natural articulation. It is in this kind of cases, Norris remarks, that 
the member affected may still be of use to the patient, the fragments 
being so firmly held together as to be displaced only upon the applica- 
tion of considerable force. 

M. Berenger Feraud, in a treatise on non-united fractures, has added 
a fifth class of pseudarthroses, which he designates as " pseudarthrose 
osteophytique ;" it being characterized by excessive osseous growths in 
irregular forms, at or near the seat of fracture. I can hardly see the 
propriety of considering this as a distinct class, inasmuch as it is a com- 
plication, which in certain conditions of the general system, under certain 
circumstances of treatment and of fracture, in certain portions of the 
osseous system, especially at the neck of the femur, may be found asso- 
ciated with either or most of the other forms of non-union described by 
Norris. 

The existence of the newly formed joints, or true diarthroses, has 
been called in (juestion by Boyer, Hewson, Chelius, 1 and others ; but the 
observations of Sylvestre, Brodie, Beclard, Home, Howship, Otto, Kuhn- 
holtz, Houston, Cooper, Langenbeck, Feraud, and Breschet prove that 

1 Malad. Chirurg., t. iii. p. 103, Paris, 1881 ; North Am er. Med and Surg. Journ., 
No. ix. p. 7, 1828 ; Trait, de Chir., trad, par Pigne, p. 150, 1836. (Norris, loc. cit.) 



DELAYED AND NON-UNION OF BROKEN BOXES. 87 

such examples are occasionally found. 1 I myself have met with several 
examples. 

A case is reported as having occurred in Boston, Massachusetts, in 
which a young man. aefc 18. broke his humerus near its middle. Before 
union had been completed it was accidentally refractured, and from this 
time the fragments showed no disposition to unite ; on the contrary, a 
gradual process of absorption took place, until at length the whole of the 
humerus disappeared : and that. too. " without any open ulcer." Eighteen 
years later he was perfectly well, and the arm was strong and useful, but 
no portion of the bone had been reproduced. 2 

Norris is a disciple of Dupuytren, and accepts his doctrine of the 
formation of callus, without reservation : consequently he finds no ne- 
cessity for but one form of delayed union, namely, that which we have 
described as belonging to the first class. In all of this class he assumes 
the existence of a cartilaginous ring or ferrule ; but we think the error 
of this exclusive theory has been sufficiently shown by the observations 
of Paget and others, and we should be warranted therefore in affirming 
the existence of as many varieties of delayed union as there are varieties 
in the manner and position of the deposit of callus, even if their actual 
existence had not been repeatedly demonstrated by dissections. 

The causes of delayed union and of non-union are either constitutional 
or local. 

The constitutional causes are chiefly those conditions of the general 
system which manifest themselves by aniemia. debility, or some peculiar 
dyscrasy. 

Sanson. Beulac. Condie. 3 and many others have mentioned cases in 
which the existence of syphilis in the system has seemed to prevent the 
formation of callus ; but, on the other hand, Lagneau and Oppenheim, 4 
incline to the opinion that syphilis exerts in this respect but little influ- 
ence : and even Berard. who admits the pertinence of one case observed 
by Nicod, concludes, after numerous researches, that it has been very 
rarely shown to affect the formation of callus. 5 

Pregnancy and lactation have been known to interfere with the union 
of bones. Werner. Hildanus. Wilson, Hertodius, Alanson, Bard, of 
New York, and Condie. of Philadelphia. 6 have all reported examples, 
in Bome of which the process of union Avas resumed and brought to a 
rapid completion as soon as the period of pregnancy was closed, or when 
lactation ceased ; but three cases reported by Sir Stephen Love Ham- 

1 Nouvelles do la Repub. des Lettro^de Bavle, p 718, 1685; Lond. Mod. Graz., xiii. 
p. 57, 1833; Beclard, Gen. Anat.. trans, by Hayward. pp. 140. 248; Transac. Med.- 
Chir. Soe. of Edinburgh, i. p. 233, 1703; Med.-Chir. Trans., viii p. 517, 1817; Otto's 
Path. Anat.. trans by South, i. p. 138; Journ. Complement., iii. p. 2'M : Dub. Med. 
Journ., viii. p. 493 ; Cooper on Prac and Disloc., fourth London ed., p. 508 ; Be- 
cherch. -ur lea Formation da Cal, 1819, p. 34. Norris, loc, cit.) 

- B si »i Med. and Surg. Journ.. July 11. 1-'.-. p. 868. 

3 Diet, de Mod. et Chir. Prat., iii. p. 402 ; Journ. do Med. Chir. et Pharm., t. \\v. 
p. 21*;. 

* K ;np de la mal. Yen., p 525; Oppenheim on Pa i x; ;7. 

. cit . p 21. * 
6 C' < . Hild.. 1681; "Wilson on the Human Skele- 

Choisie de Med., xxiv. |». 595; Med. oh-, and Enquiries, 1. 1 7 7 ii ; 

.ivi. pp. 307. 750. Norris, loc. cit.) 






88 DELAYED AND NON-UNION OF BROKEN BONES. 

mick would seem to show, what, indeed, other evidences render probable, 
that the delay was less due to the fact of the pregnancy and the lactation 
than to the debility occasionally consequent upon these conditions. 1 

As to the question whether cancer ever causes a delay in the union 
of bones, it may be said that where the fracture arises in consequence 
of a true cancerous deposit around or in the interior of the bones, pro- 
ducing absorption of their tissue, no union takes place ; but that the 
mere presence of the cancerous cachexy does not usually prevent the 
formation of callus. 

Scurvy, fevers of a low type, and, on the other hand, fevers of a 
highly inflammatory character, profuse uterine and vaginal discharges, 
and rachitis, conduce to the same result. 

The withdrawal of an habitual stimulus, and especially a change from 
a good to a low diet, or copious bleedings, may either of them delay the 
deposit of ossific matter, or prevent it altogether. 2 

Bonn has furnished two cases in which advanced age seemed to have 
retarded the formation of callus, but Horner saw a fracture of the hume- 
rus in a woman ninety years old unite in five weeks. 3 I myself have 
noticed a good many similar examples in advanced life, and it is now 
rendered quite probable that surgeons have generally overestimated the 
influence of old age upon the formation of callus. 

The local causes are, arrest of the arterial circulation by bandages ; 
arrest of the venous circulation by pressure, by rupture of veins, or by 
the formation of venous clots; 4 paralysis or impairment of the nervous 
circulation ; the occurrence of the fracture within a capsule ; obliquity 
of the fracture ; overlapping of the fragments ; interposition of a piece 
of bone, of a tendon, muscle, or of a clot of blood, or separation of the 
fragments from any cause whatever ; erysipelas ; acute phlegmonous 
inflammation ; suppuration ; necrosis ; too much motion ; exclusion of 
light and air inducing local scurvy ; wet, and especially cold and moist 
dressings ; too early use of the limb, etc. 

Treatment. — In order to hasten the consolidation when it is simply 
delayed, we resort to all of those expedients which are calculated to in- 
vigorate the general system ; and for this purpose the employment of a 
nutritious diet and the use of mineral or vegetable tonics may not be 
properly omitted; but in our experience nothing has proved so efficient 
as encouraging the patient to leave his bed and get out into the open air ; 
for which purpose, if the fracture is in the lower extremities, crutches 
will be necessary. 

As local means, we may enumerate first the removal of those local 
causes which seem to have interfered with the consolidation or with the 
union. If the fragments have been officiously disturbed, it may be 
sufficient to impose upon the limb absolute rest for a certain length of 
time ; and the fragments may be more closely pressed against each other ; 
in other cases it will be found necessary to remove the bandages, expose 
the limb freely to the light and air at least once or twice daily, and to 

1 Practical Remarks on Amputations, Fractures, etc., p. 121-. (Norris, loc. cit.) 
1 Xonis. loc cit. 3 Ibid., p. 29. 

* Geor<-<- W. Cullender, Brit. Med. Journ., Nov. 30, 1872. 



DELAYED AND NON-UNION OF BROKEN BONES. 



89 



rub it gently with the dry hand or with some moderately stimulating oil. 
so as to induce a more healthy condition of the soft parts, and encourage 

the natural circulation. 

Moving the fragments freely upon each other, sufficient to determine 
a degree of excitement in the adjacent tissues, and upon the opposing 
surfaces of the bones, and then confining them during one or two weeks 
in firm and well-fitting splints, will sometimes succeed when other means 
have failed. 

Indeed. I may say that by one or another of the simple methods now 
enumerated I have never failed, sooner or later, to effect consolidation 
in recent fractures : and it has only been in fractures of at least four, 
six. or eight months' standing that I have been compelled to resort to 
more extreme measures. 

As a means of combining immobility with compression and healthful 
exercise, the "apparatus immobile. " in many of its forms, is peculiarly 
adapted. White, of Manchester, employed a firm leather sheath for the 
thigh. H. H. Smith, of Philadelphia. 1 recommends a more complex 
artificial support, upon which the limb may be allowed to rest while in 
the act of progression. With some surgeons, the object of allowing the 
patient to walk, in fractures of the thigh or leg, is chiefly to excite in 
the tissues adjacent to the seat of fracture some degree of inflammatory 
action : but which, as the result in one of White's patients has sufficiently 
shown, may be carried too far, and even determine suppuration. 

Dr. E. R. Hudson, artificial limb maker, of Xew York, has applied 
in similar cases, which have come under my observation, an apparatus 
of his own construction, made of willow, and secured in place by leather 
straps. In case the purpose of the apparatus is to encourage bony 
union, no motion is allowed at the knee-joint. 

Recently, also. Tiemann and Stollman have adapted to one of my 
patients successfully an apparatus of their own construction. This was 
a case of ununited fracture of the femur, of long standing, and in which 
I had succeeded by the use of Brainard's drills, the gimlet, and other 
operative procedures, in securing a very close and firm fibrous union. 
The fibrous band became finally converted into bone, after the lapse of 
a fe\v months, while walking with crutches, the limb being supported by 
Mr Tiemann's very ingenious apparatus. 

Blisters, mustard cataplasms, the tincture of iodine, 2 caustics. 3 etc.. 
applied externally over the seat of fracture, can have no other effect 
than to increase moderately the congestion of the tissues, and in so far 
they may aid in the accomplishment of the bony union; but in this 
•r they are inferior to the violent twistings, flexions, and rubbings 
of the broken end- of which we have already spoken. 

Electricity was first employed by Mi-. Birch, of London, but Dr. 
Valentine Mott obtained no effect from it in two cases in which he seems 
to have given it a fair trial. 1 Lento, of the New York Hospital, has fiir- 

1 H. H. Smith. Am. Journ Med Sci., .1=0,. 1865, Jan 18? 

2 Hart.^hornf. Eclectic Rep., vol. iii. }>. 11 1. 1818. 

3 Willoughby, Am J. -urn Med Bci., Aug. 1834, p. ill. 

4 Mott, Mod. and Surg Rep., pp. 21, '■'■, r >. 



00 



DELAYED AND NON-UNION OF BROKEN BONES. 



nished an account of three cases treated in that institution by electricity 
in connection with acupuncturation ; the mode of using which was to 
pass a needle down to the periosteum on each side of the bone, and to 
attach the poles of the battery to these opposite points. Lente thinks 
that electricity employed in this way is much more efficient than when 
the polos are merely applied to the surface. He informs us also, that 
other oases than these now reported have been treated successfully in 
this hospital by means of electricity. 1 

Mercury will no doubt prove serviceable occasionally by virtue of its 
powers as an anti-syphilitic, but its beneficial influence in other cases is 
far from having been established. 



Fig. 17. 



Fig. 18. 





Tiemann & Co.'s apparatus for ununited 
fracture of the femur. 



Physick's first case, after 28 years. 
(From Am. Journ. Med. Sci.) 



The seton is said to have been first suggested by Winslow, in 1787 ; 
but, what is of much more consequence, the credit of its first successful 
application and its general introduction into practice is due to Dr. Philip 
Syng Physick, of Philadelphia, by whom it was employed in 1802. 2 

Physick used for his seton, generally, silk ribbon or French tape ; 
and this he introduced, by means of a long seton needle between the 

1 Lente, New York Journ. Med , Nov. 1850, p. 317. 

2 Physick, Med. ^Repository of New York, vol. i., 1804. 



DELAYED AND NON-UNION OF BROKEN" BONES. 



91 



Fig. 19. 




ends of the fragments. He recommended that the seton should remain 
in place four or five months, and longer if necessary, and it was his 
opinion that the failures were generally due to its being removed too 
early. At the present day, however, surgeons who employ the seton 
think it serves its purpose better when it remains in place but a few 
days, not longer, perhaps, than ten or fifteen, always taking care that 
it is removed before excessive suppuration is induced. It has been 
found especially valuable in fractures of the inferior maxilla, clavicle, 
and of the upper extremities : but in the case of the femur it has so 
frequently failed, that Dr. Physick himself did not recommend its use. 

In case the seton cannot be passed directly between the opposing 
fragments, as recommended by Physick, we may adopt the practice 
suggested by Oppenheim, and carry two setons, one on each side, close 
to the bone. 

Somme, of Antwerp, preferred a loop of wire to the silk seton em- 
ployed by Physick. 1 Seerig passed a ligature around the ligamentous 
mass connecting the two fragments, and then pro- 
ceeded to tighten the ligature until it fell oif. 2 
Dr. Hulse, of the U. S. Navy, employed stimu- 
lating injections with success in a case of non- 
union, accompanied with an external and fistulous 
opening. 3 In 1848, Dieffenbach recommended that 
ivory pegs be introduced into holes previously 
made in the bone 4 by means of a gimlet or drill, 
and Mr. Stanley has succeeded once by this 
method. 5 Mr. Hill introduced the ivory pegs 
in a case of ununited fracture of the femur, pyaemia 
supervened, and the patient died. 6 

Malgaigne. in 1837, tried to introduce acupunc- 
ture needles between the ends of an ununited frac- 
ture, but. although he thrust the needle clown to 
the bone thirty-six times, he was unable to make 
it pass once between the ends of the fragments. 
Wiesel succeeded better. In a case of ununited 
fracture of the ulna, of nine weeks' standing, 
having passed two needles between the fragments, at the end of six 
days, the needles being removed, consolidation rapidly ensued. 7 This 
practice does not differ essentially from the metallic hoop of Somme. 
It is only a modification of the seton. 

Brainard. of Chicago, lias attempted to show that setons of any kind, 
whether of wood, ivory, or metal, placed in contact with the bone, occa- 
sion absorption, caries, and necrosis, but that they never directly give 
rise to bony callus: and that the occasional success of the seton, which 



Dieffunbach's drill for un- 
united fracture. 



a*. Journ. Mod. Sci , vol. vii. p. 197. 
is, loc. cit. , p. 46. 
■ Hulse, Amer. Journ. Med. Sci., vol. sriii. p 874 
* Malgaigne, trans, by Packard, op. cit., ]>. 258, note. 

rk Journ. Med., Nov. 1854, p. 441, from Dublin Press. 
York Med Gaz., July I, 1868, from the London Lancet. 
Wiesel, Amor. Journ. Med. Sci., vol. xxxiv p. 254, July, 1844. 



02 DELAYED AND NON-UNION OF BROKEN BONES. 

success he believes to have been greatly exaggerated, has not resulted 
from any tendency to favor the formation of callus, but from the indura- 
tion and tenderness of the soft parts produced by it; circumstances 
which, by conducing to rest, indirectly favor the consolidation. 1 

In May, 1848, Miller, of Edinburgh, reported five cases treated suc- 
cessfully by subcutaneous puncture. The operation consisted in passing 
the point of a needle or small tenotomy bistoury down upon the ends of 
the bone, and freely irritating the surfaces at several points. 2 George 
F. Sandford, of Davenport, Iowa, has successfully imitated this practice 
in two cases. 3 

In 1850 Dr. William Detmold, of New York, performed the operation 
of drilling or perforating the fragments in a case of ununited fracture of 
the tibia, employing for this purpose a large gimlet. He first bored two 
holes between the opposing fragments, and then, introducing the gimlet 
one and a half inch below the fracture, he penetrated the tibia upwards 
and inwards until he had traversed, also, the upper fragment to the 
extent of an inch. In three weeks the bone appeared firm, but from this 
time the patient was not seen. 4 

Brainard employs for this same purpose a strong metallic perforator, 
consisting of a handle, into which points of different sizes may be in- 
serted, and which have been hardened so as to penetrate the hardest bone 
or even ivory in every direction easily. The points are "somewhat awl- 
shaped; but more pointed in the middle rather than like a drill, which 
leaves chips." His manner of using this instrument is as follows: "In 
case of an oblique fracture, or one with overlapping, the skin is perfo- 
rated with the instrument at such a point as to enable it to be carried 
through the ends of the fragments, to wound their surfaces, and to transfix 

Pig. 20. 



Brainard's perforator, reduced one-half. 

whatever tissue may be placed between them. After having transfixed 
them in one direction, it is withdrawn from the bone, but not from the 
skin, its direction changed, and another perforation made, and this opera- 
tion is repeated as often as may be desired." Dr. Brainard, who suc- 
ceeded by this procedure in a number of cases of ununited fracture, thinks 
it better to commence in most cases with not more than two or three 
perforations, in order that the effect produced shall not be too severe. It 
is scarcely necessary to add that, after the punctures have been made, 
the limb should be put completely at rest in appropriate splints, or in 
apparatus of some kind. 

1 Brainard, Trans. Amer. Med. Assoc, vol. vii., 1854 ; Prize Essay. Keport on 
Burgery to Illinois State Med. Soc, Mav, 1860. 

2 .Miller, New York Journ. Med., July, 1848. p. 134. 

•' Sandford, Trans. Amer. Med. Assoc, vol. iii. p. 355, 1850. 
* New York Med. Gazette, Oct. 12, 1850. 



DELAYED AND NON-UNION OF BROKEN BONES. 93 

Brainard's drills have been made latterly, not as originally directed by 
himself, with flattened points. Brainard directed that the point should 
be triangular : the flattened points are liable to catch in rotation, and to 
break. This, indeed, happened in a case operated upon by Dr. Weir, at 
the New York Hospital, in consequence of which suppuration ensued, 
with erysipelas, and the patient died. 1 

Mr. Tiemann has made for me a bone-drill which is rotated by the 
movement of a handle upon a rod or shaft composed of twisted wire, and 
which possesses the advantage of being worked with great facility and 
rapidity. Perforators of any size or shape may be fitted to the shaft at 
pleasure. This instrument may be seen illustrated by a wood-cut in the 
third, fourth, and fifth editions of this treatise. M. Berenger Feraud 
has also constructed an instrument which is practically identical with 
mine, and with which he has operated satisfactorily (Poinsot, French eel. 
of this treatise, p. 71). In my opinion neither of these instruments is 
in all respects trustworthy. They are liable to be suddenly arrested in 
hard bone, and to break. I prefer to recommend Brainard's drill, since 
it may be guided more carefully under the pressure of a sensitive and 
intelligent hand. 

I have recently employed, as an addition to the surgical procedures 
above enumerated, common shawl-pins, of steel, about four or six inches 
in length, having glass heads. Several of these are thrust between the 
ends of the bone, and are left in place seven or ten days; to be inserted 
again from time to time as may seem desirable. 

Scraping or rasping the ends of the bones is a practice which dates 
from a very early period. Mr. Brodie scraped the ends of the bones, 
and then interposed a bit of lint. 2 Mayor, in 1828, contrived to intro- 
duce an iron, previously heated in boiling water, through a canula, and 
thus brought the heat to bear directly upon the ends of the fragments; 
and. by repeating the application several times, a cure was effected. 3 

Resection of the ends of the bones, first brought into notice by White, 
of Manchester, in 1760, 4 and opposed by Brodie 5 as dangerous, and by 
Malgaigne regarded as generally useless or unnecessary, has still been 
practised a great number of times, with more or less success. It is 
especially applicable to superficial bones, and in cases where the bones 
overlap. Its value is now sufficiently demonstrated, except, perhaps, in 
the case of the femur. 

Roux practised resection in one instance, and then managed to engage 
the point of one of the fragments in the medullary canal of the other. 
I have succeeded in doing the same. 

White, of Manchester, Henry Cline, of London, Hewson, Barton, and 
Norris, of Philadelphia, have applied caustics directly to the ends of the 
fragments, after having exposed them by a free incision. 7 Petit applied 
the actual cautery. 8 

Tying the fragments together by means of metallic ligatures after a 

1 Dr. Weir's Report to Path. 8oc., Med. Record, March 8, 1879. 

-' Brodie, Lond. Med. Gaz., July. 1834. '■ Norris, loc. <'it.. p. 18. 

4 Diet, do Mod., vol. xxiii. p. 503. 

5 Brodie, New York Journ . vol. viii. 1-t ser., p. 133. 

lis, loc. cit. , p. 40. " Ibid. 8 Ibid. 



94 DELAYED AND NON-UNION OF BROKEN BONES. 

recent fracture is as old as the days of Hippocrates ; but in 1805 Horeau 
adopted the same procedure in a ease of ununited fracture; 1 since which 
date it has been practised successfully by many surgeons. My own 
experience confirms the value of the method, especially when the frag- 
ments overlap. 

E. S. Gaillard, of Louisville, Ky., proposes to secure the fragments 
in place by means of a metallic pin. The instrument which he employs 
is composed of a steel shaft with a handle, a silver sheath, and a brass 
nut. For a broken femur the shaft is six inches long, its lower extremity 
being constructed like a gimlet, Avhile two and a half inches of its upper 
extremity are cut for a male screw, being intended to carry the brass 
nut. The sheath is three inches long. 

Through an incision made over the seat of fracture, the sheath, detached 
from the shaft, is carried down to the bone. The shaft is then passed 

Fig. 21. 



Gaillard's instrument for ununited fractures. 




through the sheath, and made to penetrate and transfix the two frag- 
ments; as soon as this is accomplished, the nut is turned down firmly 
upon the top of the sheath, and apposition of the fragments is thus 
secured. The whole instrument is permitted to remain until bony union 
is effected. 2 

Fitzgerald, of Melbourne, has practised successfully the injection of 
five to ten minims of glacial acetic acid between the fragments. It 
causes at first a sharp pain, and he thinks it accomplishes its beneficial 
results by causing a resolution and absorption of the interposed fibrinous 
cartilaginous materials and encouraging the substitution of bone. 3 

Finally, having thus brought rapidly before us all of the various 
modes of treatment which have been suggested and practised for non- 
union of broken bones, we are prepared to affirm the following conclu^ 
sions, or summary of what has been our own practice, and of what we 
believe ought to be the general course of procedure in these cases : 

First. Improve the condition of the general system. 

Second. Remove as far as possible the local impediments, such as a 
separation of the fragments, local paralysis, local scurvy resulting from 
long exclusion from light and air, congestions, etc. 

Third. Increase the action of the tissues immediately adjacent to the 
fracture, upon which tissues, rather than upon the bone, as Malgaigne 

1 Norris, loc. eit., p. 49. 

2 E. S. Gaillard, New York Journ. Med , Nov. 1865. 

3 Boston Med. and Surg. Journ., Aug. 15, 1878, from Medical Press and Circular. 



DELAYED AND NON-UNION OF BROKEN BONES. 95 

thinks, the formation of callus depends : a theory which, as applied to 
old and ununited fractures, we are not prepared to deny. This may be 
accomplished by frictions, and violent flexions of the limb at the seat of 
fracture : possibly in some measure by the application of vesicants or of 
other stimulants to the skin itself. 

Fourth. Employ again compression and rest for a period of from two 
to four or eight weeks. 

Fifth. Resort to the method recommended by Brainard, or to some of 
its modifications, to interfragmentary injections, etc. 

Sixth. If in the lower extremity, allow the patient to walk about with 
the fragments well supported. 

Seventh. If the fracture is not in the femur, and as an extreme 
measure, employ the seton, or resection, and the wire suture. 

Where these measures have failed, after a fair trial, we should cease 
to hope for success from operative measures, and subsequently rely only 
upon retentive apparatus, under the continued use of which consolidation 
is sometimes effected. 

More precise rules of procedure will be given hereafter in connection 
with the various fractures. 

Dr. Frank Muhlenberg, of Philadelphia, has made a very valuable 
contribution to this subject in a collection of cases drawn from the 
medical journals, and published in a tabular form by Dr. Agnew in his 
treatise on surgery. The student will do well to consult this table, 
which occupies fifty-seven pages of Dr. Agnew's excellent book. In a 
summary of the whole number, 656 cases, it is stated that 5Q5 were 
males, and 91 females. The youngest was 13 years old and the oldest 
"<». the largest number being within 28 and 40 years. In 61 the frac- 
tures had existed less than three months ; the shortest period being- 
three weeks, and the longest ten years. The whole number cured by 
the various plans of treatment was 385 ; of the remaining 271, 43 were 
relieved — that is, the amount of motion between the fragments was less- 
ened — in 204 no benefit was derived from the operation, 19 proved 
fatal, and in 5 the result is not known. 1 

It might have been well to have noted what proportion were cured 
after five months, after six months, and after one year, since I would 
not regard a case as properly one of non-union until after the fifth month. 

It is also scarcely necessary to say that unsuccessful, and especially 
fatal, cases are hot so likely to find their way into the journals as suc- 
■ that it must be assumed that the actual proportion of 
failures is greater than these tables represent. 

1 Principles and Practice of Sur^erv, by D. Hayes Agnew, M.D., LL.D., Prof, of 
Surg, in Univ. of Pa., vol. i. pp. 702-808. 



96 BENDING, PARTIAL FRACTURES, AND FISSURES. 



CHAPTER VIII. 

INCOMPLETE FRACTURES. 
BENDING, PARTIAL FRACTURES, AND FISSURES OF THE LONG BONES. 

§ 1. Bending of the Long Bones. 

Strictly speaking, no bone can be much bent without being also 
more or less broken, and that whether it immediately or spontaneously 
resumes its position or not ; for, if the bending and straightening of the 
bone be repeated a sufficient number of times, the yielding of the fibres 
will become appaient, and at length the separation will be complete. 
The first of this series of flexions was quite as much responsible for this 
result as the last, and, no doubt, performed its share in the production 
of the complete fracture. 

There could be no impropriety, therefore, in speaking of a bending 
of the bones as a variety of incomplete fractures, as I have done in the 
first section of my " Report on Deformities after Fractures," made to 
the American Medical Association in 1855. l 

They have been called, not inappropriately, interperiosteal fractures, 
since in these cases the periosteum is not broken. M. Blandin thinks 
that the outer and semicartilaginous laminae of the bone also do not 
break, while the deeper laminae suffer an actual disruption. 2 But it is 
quite as probable that in a majority of cases the true pathological condi- 
tion is a compression of the bony fibres upon one side, and a correspond- 
ing expansion upon the opposite side, with only a slight interstitial frac- 
ture, too trivial to be easily recognized even in the dissection. Sometimes, 
as I have several times observed in my experiments on the bones of 
chickens, when the bones are small, and the bending is near the centre 
of the shaft, the whole of the laminae on the side of the retiring angle 
produced by the bending are doubled in, or indented toward the hollow 
of the bone, so that the fibres on the side of the salient angle are not 
even stretched, and much less broken. In such cases the interstitial dis- 
ruption, if it exist at all — and I think it does — first takes place in the 
deeper layers of the retiring angle. 

I might, therefore, feel justified in continuing to call these cases par- 
tial fractures, or, perhaps, interstitial fractures; but I believe that the 
whole subject will be rendered more intelligible if I call them simply 
bending of the bones, as distinguished from those other and more pal- 
pably partial fractures of which I shall speak presently. 

1 Op. cit, pp. 421-422. 

- M;u kliiiin '.- Obs. on the Surg. Practice of Paris, London Med. Chir. Rev., vol. 
xxxiv. p. 473, 1841. 



BENDING OF THE LONG BONES. 97 

1. Bending, with an immediate and spontaneous restoration of the 

bone to its original form. — The possibility of this accident, to which. 
however, surgical writers have hitherto made no distinct allusion, is 
rendered certain by the following experiments: 

Experiment 1. — July 16, 1857. I bent the tibia of a Shanghai 
chicken, four weeks old, at about the middle of the bone. It was bent 
to an angle of quite twenty-five degrees, but it was not felt or heard to 
break. It immediately and spontaneously resumed the straight position. 

July 18, two days after the bending, I dissected the limb, and found 
no trace of the injury, either within or without the bone, unless I except 
a very minute blood-clot in the centre of the shaft. 

Experiment '2. — I bent the leg of a chicken, four weeks old, at the 
same point and to the same degree. It immediately resumed the straight 
position. 

Dissection after two days. Nothing abnormal except a small blood- 
clot in the centre of the bone, and a slight disorganization of the medulla. 

Experiments 3 and 4. — Bent both legs of a chicken, four Aveeks old, 
at the same point and in the same manner. They immediately resumed 
their positions. 

Dissection after two days. No lesions or morbid appearances which 
I could detect. 

Experiments 5 and 6. — Bent both wings of a chicken four weeks old. 
bent the right wing to an angle of thirty-five degrees. I did not feel 
them break. Both resumed their positions spontaneously. 

Dissection after two days. No lesions or other morbid appearances. 

Experiment 7. — July 16, 1857, I bent the leg of a Shanghai chicken, 
five weeks old. below the knee and about the middle of the bone. It 
was bent to an angle of about twenty-five degrees, but the bone was not 
felt or heard to break. It immediately and spontaneously resumed the 
straight position. 

July 20, four days after the bending, I dissected the leg, but could not 
discover any trace of the injury, except that there was a very minute 
ossific deposit in the centre of the bone at the point at which I suppose 
it to have been bent. 

Experiment 8. — July 16, 1857, I bent the right leg of a Shanghai 
chicken, five weeks old, at the same point as in the first experiment, and 
to the same extent. The bone did not seem to break, but it immediately 
and spontaneously resumed the straight position. 

Dissection after four days. Nothing appeared to indicate the seat of 
the bending, except a small clot of blood in the centre of the shaft. 

Experiment 9. — Bent the leg of a chicken, six weeks old, in the same 
manner and to the same degree as in the other examples. It resumed 
its position spontaneously. 

Dissection after ten days. No evidence of injury of any kind ; the 
bone being sound and straight. 

These experiments were made in connection with others to which more 
especial reference will hereafter be made. They are selected, and consti- 
tute the whole number of those in which 1 did not feel the bone break 
or crack under my fingers. In every instance the bone sprung back im- 
mediately and spontaneously to it- natural form. In no instance could 



*»8 HEX DIXO, PARTIAL FRACTURES, AND FISSURES. 

I afterwards discover any trace of lesion or sign indicating the point at 
which the bone had been hent before dissection, nor did dissection itself 
disclose anything but the most inconsiderable marks, and that in but 
three examples. 

I infer, therefore, not forgetting the caution with which the conclu- 
sions from all such experiments ought to be applied to similar accidents 
upon the human skeleton, that whenever the bones of healthy infants 
have been slightly bent and not broken, they will, probably, in most 
cases, unless prevented by causes foreign to the bones themselves, spon- 
taneously and immediately resume their position, and that no sign will 
remain to indicate that a bending has occurred. The accident will not 
be recognized, and, as a further inference, this bending does not belong- 
to that class of cases of which I shall next speak. 

2. Bending, without immediate and spontaneous restoration of the 
bone to its original form. — "Dethleef, believing that he had broken the 
two bones of the legs of a dog, found the fibula bent without a fracture. 
Similar results were obtained by Duhamel upon a lamb; by Troja upon 
a pigeon ; and I have myself twice succeeded in bending the fibula while 
breaking the tibia. The possibility of simple curvature is then not con- 
testable ' ' (the writer means to say that the possibility of a simple curva- 
ture remaining permanently bent is not contestable), "but we must 
observe that they have never been obtained except upon young animals, 
and that they have been unable to maintain themselves permanently 
except through the aid of a fracture and displacement of a neighboring 
bone ; and there is a wide difference between these and those pretended 
curvatures which some believe they have seen in man, in which the curved 
bone maintains itself, and resists perfect reduction until the fracture is 
complete." 1 

In this single paragraph Malgaigne seems to have given a fair summary 
of the testimony upon this point. With the exception of these and a 
few other similar examples, some of which I think I have observed my- 
self, where one of the bones of the forearm has been broken and the 
other bent, I know T of no well-attested cases of a permanent bending; 
using the term bending in a sense distinguished from a partial fracture. 

If, in numerous cases mentioned by surgical writers, there has seemed 
to be probable evidence that the permanent bending was unaccompanied 
with fracture, there has always been wanting, so far as I know, the posi- 
tive evidence of dissection. The example of partial fracture mentioned 
by Fergusson, and represented by a drawing, is described as having 
also, "toward the lower extremity, a slight indentation and curve." 2 
This was the radius of a child ; but how long the child survived the 
accident, and what was the condition of the ulna, we are not informed. 
The observations made by Jurine, of Geneva, in Switzerland, 3 by Barton 4 
and Norris, 5 of Philadelphia, all fail to furnish any such conclusive evi- 
dence of the correctness of their own views. Norris says that " Thierry, 
of Bordeaux, Martin, and Chevalier, had all met with and published 

1 Traite des Frac, etc., par L. F. Malgaigne, torn. i. p. 48. 

2 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208. 

3 Journ. de Corvisart et Boyer, torn. xx. p. 278, etc. 

* Phila. Med. Recorder, 1821. 5 Phila. Med. Journ., vol. xxix. p. 233, 1842. 



PARTIAL FRACTURE OF THE LOXG BOXES. 



99 



cases of this kind prior to the appearance of Jurine's paper (in 1810), 
the former of whom asserts that Haller. in experimenting upon the sub- 
ject, had been able satisfactorily to produce the same accident in young 
animals."' For myself, I cannot say how much con- 
fidence we ought to place in these assertions of Thierry, 
Martin, and Chevalier, having never seen the papers re- 
ferred to : but since Dr. Norris has neglected to inform 
us whether any dissections were ever made, we shall not 
be expected to regard their testimony as conclusive. 

With the qualifications now made, Gibson was more 
nearly right when he said, -> Dupuytren and Dr. John 
Rhea Barton have each furnished accounts of bent bones. 
There are no such injuries, however, in my opinion ; 
such cases being, in reality, partial fractures from which 
deformities result upon the same principle that a piece of 
tough wood, like oak or hickory, if broken half through, 
may be inclined to one side and shortened, although 
still held together by interlocking of fibres. Many speci- 
mens in my cabinet, and in the Wistar Museum, attest 
the accuracy of this assertion." 1 

In my own experiments upon the chicken, the bones 
uniformly resumed their original position as soon as the 
restraining force was removed, unless a fracture occurred, and this not- 
withstanding the bones were bent quite abruptly and to an angle of 
twenty-five degrees. Certainly, if the bones of children may be bent 
during life and be made to retain this position without a fracture, then 
the same thing might be done upon the bones of children recently dead, 
and, by successful experiments, this long-agitated question might be 
easily and forever put to rest. 

It will be understood that our observations are confined to the long 
bones. That the flat bones, and especially the bones of the cranium, in 
childhood, may be indented by blows, and remain in this condition, is 
undeniable. Scultetus says he had seen " the skull pressed down in 
children, without a fracture, so that those who touch or look upon it can 
perceive a small pit," 2 and it has been mentioned by many writers since, 
and perhaps before his day. I have myself published two examples of 
it in the second volume of the Buffalo Medical Journal, 6 and since the 
date of that publication I have met with others. 




Case mentioned 
by Fergusson. 



§ 2. Partial Fracture of the Long Bones. 

1. Partial Fracture with immediate and spontaneous restoration 
of the bone to its original form. — No writer seems to have given any 
special attention to the form of fracture now under consideration, although 
its existence appears to have been occasionally recognized. In the case 
reported by Camper, in 1765, of a partial fracture of the tibia, the bone 

1 Institutes and Practice of Surgery, by Wm. Gibson, Phi la., 1881, vol. i. p. 2o4. 

2 The Chirurgeon'e Storehouse, by Johannes Scultetus, 1674, p. 126. 

8 Op. cit., p. 347, 1840. Cases 1 and 2. 



100 BENDING, PARTIAL FRACTURES, AND FISSURES. 

had regained its natural form, but whether immediately after the accident 
occurred, or at a later period, I am not able to learn. 1 Jurine, Gulliver, 
and others, have noticed a gradual straightening of the bone after a 
partial fracture, so that its complete restoration has been accomplished 
after several weeks or months; but this, although partly due to the same 
cause which produces occasionally an immediate restoration, namely, its 
elasticity, is in part also due to other causes, and will be more properly 
considered under the next division of partial fractures. 

Says Malgaigne : " Finally, at other times the fracture takes place 
without opening and without curvature; the only sign which one can 
recognize is a yielding of the bone under the pressure of the finger at the 
point of fracture ; yet upon the living subject we may see the same symp- 
tom pertain to complete and simple fractures without displacement." 2 

In the following report of one of M. Blandin's clinics the accident is 
described a little more distinctly : "In some cases of fracture of the 
clavicle occurring about the middle of the bone in young subjects, dis- 
placement of the fragments does not immediately take place, thus giving 
rise to a risk of an error in diagnosis, by which the ultimate probability 
of a cure is diminished. A lad seventeen years of age was recently 
admitted into the Hotel Dieu, under the care of M. Blanclin, having, a 
few days previously, fallen upon one of his comrades while playing with 
him, when he instantly experienced pain and a cracking sensation about 
the middle of the left clavicle, where there soon formed a tumor, which, 
increasing, induced him to enter the hospital. On examination, the 
swelling was found to occupy the middle of the clavicle ; it was about 
as large as half a hen's egg, ovoid in shape, well circumscribed, colorless, 
and hard, but sensible to pressure. There was not any deformity of the 
shoulder, nor any abnormal modification of the axis of the bone, to indi- 
cate the existence of a fracture ; and although the different movements 
of the arm caused pain in the shoulder, yet they could be made without 
much difficulty. 

" The symptoms in this case would lead to the belief that it was a 
case of simple periostitis, caused by external violence ; but M. Blandin 
at once decided that there existed a fracture of the bone, having seen a 
similar case previously at the Hopital Beaujon, where the tumor was 
treated as traumatic periostitis, the patient merely carrying his arm in 
a sling, until, by a sudden movement of the limb, displacement of the 
fragments was produced, and clearly demonstrated the existence of a 
fracture. A second case occurring soon afterward, M. Blandin profited 
by the experience gained from the preceding, and by moving the frag- 
ments of the broken clavicle on each other, obtained motion and crepitus. 
Still these indications were not so clear, that M. Marjolin could diag- 
nosticate a fracture ; he was of opinion that the case was one of exostosis, 
probably syphilitic, and the crepitus, he believed, depended on an erosion 
of the osseous surface. In consequence, the patient was left to himself, 
until a movement of the arm gave proof of the fracture by the displace- 
ment of the broken portions of the bones. 

1 Essays and Obs. Phvs. and Lit. of Soc. of Edinburgh, vol. iii. p. 527. 

2 Op. cit., torn. i. p. 50. 



PARTIAL FRACTURE OF THE LOXG BOXES. 101 

" Two other cases occurring in young subjects have been admitted 
since in the Hotel Pieu. under the care of M. Blandin, one of whom 
was purposely left without surgical assistance, while Desault's bandage 
was applied to the other. The former soon showed evidence of consecutive 
displacement : the latter was cured without any deformity following. 

" The surgeon may diagnosticate a fracture, without displacement of the 
middle portion of the clavicle, when a circumscribed tumor forms in that 
part of young subjects, consecutive on a fall on the shoulder, and motion 
of the fragments, with crepitus, can be detected, there not being any 
syphilitic taint in the constitution." 1 

The following examples, which have come under my own observa- 
tion, will illustrate more completely the usual history and symptoms 
of these cases: 

A. B.. aged three years, fell from the sofa upon the floor, striking, it 
is thought, on her right shoulder. Two days after this, she fell again, 
and then for the first time Mr. B. noticed the deformity. She was 
brought to me three days after the second fell. There existed then a 
round, smooth projection at the outer end of the middle third of the 
clavicle. It felt hard, like bone. The line of the clavicle was not 
changed. I advised a handkerchief sling, simply to steady and support 
the arm. Seven months after the accident, she fell sick and died. The 
projection continued at the time of death, only slightly diminished. 

H. >.. aged six years, was thrown from a horse, partially breaking 
his left clavicle, near its middle. Dr. Sprague, of Buffalo, was employed. 
The projection in front was for several days very apparent, and was 
examined by myself at Dr. Sprague's request. The bone did not seem 
to be out of line. Five years after the accident, I examined the lad, 
and could not find any trace of the original injury. 

September 25. 1855, Mrs. T. C. brought to me her infant child, then 
but two weeks old. Upon the left clavicle, at a point a little nearer the 
acromion process than the sternum, was an oblong swelling, three-quarters 
of an inch in length, smooth and hard like callus ; the skin was not 
reddened, nor tender. There was no motion or crepitus, and the line of 
the axis of the bone was perfect. The mother, who had been put to bed 
by a midwife, thinks the injury occurred in the act of birth, although 
-he did not notice the swelling until a week after. 

October 20. Nearly one month later, I found no change in the con- 
dition of the bone ; the hard lump remained, but it was still entirely 
free from tenderness. I have not seen the child since. 

An infant boy. three years old. fell, August 12, 1857, from the hands 
of the nurse. The child cried, but the point of injury was not detected 
until the third or fourth day. although the mother examined the shoulders 
and neck carefully at the time. She is quite certain that if any swelling 
or discoloration had been present, -lie would have seen it then, or on the 
subsequent days, while washing and dressing the child. When first seen 
it was very distinct, bur not so large as ;ir present. 

1 Am. Journ. Med. 8ci., vol. rxxi. p. 47:!. from Journ. de Med. et Ohiruig. Prat., 
July. 



102 BENDING," PARTIAL FRACTURES, AND FISSURES. 

August 19. The child was brought to me. A little to the sternal 
Bide of the middle of the right clavicle there was an oblong node-like 
swelling, of the size of the half of a pigeon's egg, hard, smooth, and 
feeling like bone; there was no discoloration or swelling of the integu- 
ments: no crepitus or motion ; the line of the clavicle seemed nearly or 
quite unchanged. 

I have not noticed this variety of accident in any other bone except 
the clavicle, yet it is not improbable that it happens occasionally, and 
perhaps quite as often, in other long bones, but that its existence is not 
elsewhere so easily recognized. According to Poinsot, M. Demons has 
seen a similar case in the humerus of a newly born infant. 

Of one hundred and fifty-seven fractures of the clavicle recorded by 
me, thirty -four were partial fractures; and of these at least eleven were 
spontaneously and immediately restored to their natural axes. 

In explanation of the fact that hospital surgeons have not observed 
so large a proportion of partial fractures of the clavicle, it must be stated 
that most of these cases of partial fracture were drawn from private 
practice. Accidents of this class may be often met with in private 
practice and in dispensaries, but they are seldom found in hospitals. 

Experiment. — In fourteen experiments upon the bones of chickens, 
a partial fracture, with immediate and spontaneous restoration, has 
occurred but once. In nine of these cases the bones were only bent, 
and in five they were partially broken ; an immediate restoration has 
occurred, therefore, in one case out of five of partial fractures ; while in 
my recorded examples of partial fracture of the clavicle it has been 
noticed about once in every four or five cases. The following is the 
experiment to which I have referred: 

I produced a partial fracture of the tibia in a chicken six weeks old. 
The fracture was near the middle of the bone. It was felt to break 
under my finger; but, on removing the pressure, it immediately and 
spontaneously resumed the straight position. 

The limb was dissected on the tenth day. The line of the axis of the 
bone was perfect, but on the fractured side was a node-like enlargement, 
sufficient to be distinctly felt and seen before the soft parts were 
removed. 

Pathology. — In no case, except in my single experiment upon the 
bone of a chicken, has the actual condition been determined by dissec- 
tion, and if any question has existed heretofore as to the possibility of an 
immediate and spontaneous restoration after a partial fracture, this ex- 
periment ought to decide it in the affirmative; but then the first nine 
experiments already quoted have shown that a mere bending with imme- 
diate restoration leaves no such traces or signs as have been described as 
following these accidents. "We have, therefore, the negative argument 
that, since a bending with restoration leaves no signs, the examples, 
reported by myself and others as having occurred, and as having been 
followed by a node-like swelling, etc., must have been partial fractures. 
Moreover, in one of the cases of immediate restoration reported by 
Blandin, there was a feeble crepitus; and in another, the subsequent 
displacement proved the correctness of his diagnosis. The same has been 
noticed by myself in several examples. 



PARTIAL FRACTURE OF THE LONG BOXES. 103 

"We conclude, then, that these are examples of partial fracture, but 
that the number of bony fibres which have given way are too inconsider- 
able, as compared with those not broken, to affect materially the elasticity 
of the bone. 

Diagnosis. — The diagnosis will depend somewhat upon the history of 
the accident as well as upon the present symptoms. In no instance, 
where I could ascertain the cause, have I known an incomplete fracture 
of this variety produced by any other than an indirect blow: and where 
the clavicle has been the seat of the fracture, the counter-blow has been 
received upon the end of the shoulder. The fact possesses, therefore, 
equal significance in its relation to either of the varieties of partial frac- 
ture: but in the case of a partial fracture with a permanent curvature, 
the diagnosis would be complete without the history, while in this case 
it might not be. and a knowledge of the manner in which the accident 
occurred would, therefore, be of great importance. 

The signs, then, after a knowledge of the fact that a blow has been 
received upon the shoulder, are a node-like swelling upon the anterior or 
upper face of the clavicle, generally in its middle third, this swelling- 
being hard, smooth, oblong: the skin only slightly or not at all swollen 
or tender, and in no way discolored, as it would have been had the 
swelling upon the bone been the result of a direct blow : and the line of 
the axis of the bone being unchanged. I have occasionally detected 
motion and crepitus at the point of injury, and we have seen that Blandin 
was able to detect both in one instance : but it has never occurred to me 
to see the swelling upon the bone until two or three days after the injury 
was received. We are not very likely, therefore, to recognize this acci- 
dent immediately after its occurrence. 

Treatment. — In the case of the clavicle, neither bandages, slings, 
compresses, nor lotions, can be of much service. Yet no harm can arise 
from employing a simple sling and roller to confine the arm : and it is 
always proper to enjoin some degree of care in using the arm of the 
injured side. The consolidation will be speedily accomplished, and after 
a time the ensheathing callus will wholly disappear. 

If a similar accident should occur in any other of the long bones, as 
retentive and precautionary means, splints ought to be applied, at least 
for a few days. 

2. Partial Fracture^ without immediate and spontaneous restoration 
of the bone to its natural form. — The causes of this accident are the 
same as those which produce simple bending, or partial fracture with 
immediate and spontaneous restoration, from which latter they differ 
probably in the greater extent of the bony lesion. Perhaps, also, they 
differ sometimes in the peculiar form and degree of the denticulation at 
the Beat of the fracture: in consequence of which an antagonism of the 
fibre- take- place, preventing a restoration of the bone To it- original 
form. 

Very few Burgeons have spoken of partial fracture in the clavicle, 
while Jurine. Syne-. Liston, Miller. Norris, and many other-, have 
declared that it is much more frequent in the bene- of the forearm than 
elsewhere. This doe- not agree with my experience, according to which 
it occurs oftener in the clavicle than in the forearm; a discrepancy which 



104 BENDING, PARTIAL FRACTURES, AND FISSURES. 



I cannot very well explain, except by supposing that, in the case of the 
clavicle, the accident has either been overlooked entirely or misappre- 
hended. Blandin, who, Ave have seen, has reported five cases of partial 
fracture of the clavicle with immediate restoration, states distinctly that 



Fig. 23. 



Fig. 24. 




Partial fracture with- 
out restoration of the 
bone to its natural form. 



•'llli'illHiiHlli 1 '" 
Partial fracture of the clavicle without spontaneous restoration. 
From nature ; taken three weeks after the accident. 

in two of these cases distinguished surgeons of the 
Hopital Beaujon and Hotel Dieu failed to recog- 
nize it. 

Says Turner: "The next I shall descend to is 
that of the clavicle or collar-bone, which I have 
found the most frequently overlooked, I think, of 
any other, till it has been sometimes too late to 
remedy, especially among the children of poor 
people; for, though they find these little ones to 
wince, scream, or cry, upon the taking off or putting on their clothes, 
yet, seeing that they suffer the handling of their wrists and arms, though 
it be with pain, they suspect only some sprain or wrench, that will go 
away of itself, without regarding anything further or looking out for 
help; whereas, this fracture discovers itself as easily as most others. 
For not only the eye, in examining or taking a view of the part, may 
plainly perceive a bunching out or protuberance of the bones when the 
neck is bared for that purpose, with a sinking down in the middle or on 
one side thereof, w r hich will be still more obvious on comparing it with 
its fellow on the other side ; but when it is more obscure, and the bone, 
as it were, cracked only — a semi-fracture, as we say — yet, by pressing 
hard upon the part, from one extremity to the other, you will find your 
patient crying out when you come upon the place ; and by your fingers, 
so examining, sometimes perceive a sinking further down, with a crack- 
ling of the bone itself." 1 

Erichsen, who regards all of these cases as mere bendings of the bones, 
remarks that it "most commonly occurs in the long bones, especially the 



1 Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 255. 



PARTIAL FRACTURE OF THE LONG BOXES. 



105 



Fig. 



clavicle, the radius, and the femur." 1 He says, moreover, "Fracture of 
the clavicle in infants not unfrequently occurs, and is apt to be over- 
looked. The child cries and suffers pain whenever the arm is moved. 
On examination, an irregularity, with some protuberance, will be felt 
about the centre of the bone." 2 The reader will not fail to recognize in 
these symptoms the incomplete fracture of which we are now speaking, 
although Eriehsen evidently believes them to be examples of complete 
fracture. 

In addition to this testimony as to the frequency of these fractures in 
the clavicle. I will only mention that Johnson, in his review of Mark- 
ham's Observations on the Surgical Practice of .PaWs r says that "many 
surgeons have noticed the incomplete fracture of the clavicle, as of other 
bones, which takes place in the young." 3 

Pathology. — The following experiment will assist in the elucidation of 
this part of our subject: 

Experiment. — I bent the leg of a chicken five weeks old. It cracked 
under my fingers, and remained bent. Having waited a few seconds, 
and finding that it was not restored to position, I pressed 
upon it and made it straight. The chicken walked off 
without any limp. 

On the fourth day. before dissection, the bone looked 
as if it was still bent : but. on removing the soft parts, 
the line of the axis of the bone was found to be straight. 
The areolar tissue under the skin was infiltrated with 
lymph, which was most abundant near the fracture, and 
gradually diminished toward each extremity of the limb. 
This effusion was confined almost entirely to the front 
of the limb, or to that side which had been broken, and 
constituted the greater part of the enlargement, which 
I had noticed before the dissection was commenced, and 
which then felt like bone. 

< >n the front of the bone, also, underneath the peri- 
osteum, there was a loose, honeycomb deposit of en- 
>heathing callus, about one line in thickness, and 
extending upwards and downwards about half an inch. 
This callus surrounded the bone in three-fourths of its 
circumference: but there was no callus on its posterior 
surface. It was also deficient exactly along the line of 
fracture, in front and on the sides, in consequence of 
which an oblique groove remained, indicating the seat 
of the fracture. 

In three other experiments, the particulars of which 
are detailed in the earlier editions of this book, similar 
results were obtained. 

early a- the year 107-]. a dissection made by 
Glaser demonstrated incontestable the existence of par- 
tial fracture- in the shaft, and in the direction <»f the diameter of lone 



Partial fracture; 
after union is con- 
summated. 



i ce and Art of Surgery, Phila. <•<!.. 1854, )>. 180. 

' "p. cit., p. 5i:, 

., vol. xxxiv. p. 471. 1841. 



106 BENDING, PARTIAL FRACTURES, AND FISSURES. 

bones. 1 Camper, in 1765, again described a specimen which he had 
seen; 2 and Bonn, in 1783, added a third positive observation. 3 

M. Gimele is, therefore, in error when he ascribes to Campaignac the 
credit of having first proven by dissection their existence, in a paper 
communicated to the Academy of Medicine at Paris, in 1826. Cam- 
paignac, however, seems to have been the first who described very 
particularly the condition of this fracture. He has recorded the history 
and dissection of two cases, one of which occurred in the fibula, and 
one in the tibia. The first of these cases was a girl twelve years old, 
who survived the accident just eight weeks. The fracture had occurred 
near the middle of the bone, and upon the interior and internal side: 
in which direction, resting against the tibia, the bone was found 
inclined. "The bony fibres had been broken at different lengths. 
almost exactly like what takes place in the branch of a tree which has 
been partially broken ; and, as we see sometimes in this latter case, the 
bundles of splintered bony fibres abutted upon themselves, and did not 
take their places when we endeavored to restore them; so the abnormal 
angle which the fibula represented could not be effaced, the ends of the 
divided fasciculi not restoring themselves to their respective places. This 
disposition might be especially seen toward the anterior part of the inter- 
nal face, where a packet of fibres, coming from below, was braced against 
the upper lip of the division, which it thus held open. This opening at 
first made me think that the fragments could not have been well consoli- 
dated, but I assured myself that it was, and the fact was subsequently 
confirmed by the Academy of Medicine: all the points which were in 
contact were found intimately united." 4 

Diagnosis. — The diagnosis is not difficult. The distortion indicates 
sufficiently the existence of a fracture, while the complete absence of 
crepitus in nearly all cases, and of either overlapping or lateral displace- 
ment, must generally, especially where the accident has occurred in a 
child, sufficiently indicate that the fracture is incomplete. It will assist 
the diagnosis, also, to notice that these accidents are almost confined to 
the middle third of the long bones; and they are produced usually by 
a bending of the bones, the forces operating upon the extremities, and 
not directly upon the point which is broken. 

In complete fractures, also, preternatural mobility is so constant a sign 
as to be regarded as diagnostic, while here there is almost always a great 
degree of immobility at the seat of fracture. The angle made by the 
projecting extremities is usually rather gentle and smooth : at other times 
it is abrupt, indicating a greater amount of fracture, or that the outer 
fibres are broken more irregularly. The power of using the limb is 
generally sensibly impaired, but not completely lost. 

Treatment — Jurine, Murat, Campaignac, Gulliver, Malgaigne, with 
some others, have noticed the fact that it is often difficult, and some- 
times quite impossible, to restore these bones to position ; a circumstance 

1 Malgaigne, op. cit., p. 44, from Th. Boneti Sepulchretum ,1700, torn. iii. p. 424. 

2 Essay- and Obs. Phys. and Lit. of Soc. of Edinburgh, 1771, vol. iii. p. 537. 

; Malgaigne, op. cit., p. 44, from Descript. Thes. Ossium Morb. Hoviani, 1783. 
4 Do Fractures Incompletes et des Fractures Longitudinales des Os des Membres; 
par J. A. J. Campaignac. Paris, 1829, pp. 9, 10. 



PARTIAL FRACTURE OF THE LONG BONES. 107 

which they have justly ascribed to that condition of the fragments de- 
scribed by Campaignac. The broken extremities of the fasciculi become 
braced against each other, and effectually resist all efforts to straighten 
the bone : unless, indeed, so much force is used as to render the frac- 
ture complete: a result which, if it should chance to happen, need not 
occasion any alarm, since, while it enables us at once to restore the bone 
to line, it does not much increase the danger of lateral displacement and 
overlapping. That the fracture has become complete we may know by 
a sudden sensation of cracking, by the increased mobility, and by the 
crepitus, which is now easily developed. 

But we need not, on the other hand, be overanxious to straighten the 
bone completely, since experience has shown that after the lapse of a 
few weeks or months the natural form is usually restored spontaneously. 
I am not now speaking of those cases in wdiich the restoration occurs 
immediately, in which it is probable that the splintered fibres offer no re- 
sistance to the restoration ; but only of those in which the bone straightens 
so gradually as to induce a belief that the broken ends are the cause of 
the resistance. To this variety of accident belong cases one, five, six. 
seven, and eight, published in my Report on Deformities after Frac- 
tures : 2 in one of which the natural axis was resumed in less than four 
weeks. In a case mentioned by Gulliver, it required about the same 
time to render the bones of the forearm perfectly straight ; and in one 
case mentioned by Jurine, at the end of six months it was " difficult to 
say which arm had been broken, and at the end of one year it was im- 
possible." 

Jurine attributes this restoration to " muscular action, or more espe- 
cially to the reaction of the compressed bony plates: " but while it is 
easy to understand how the reaction of the compressed fibres may ac- 
complish the gradual restoration, I am unable to understand in what 
manner muscular action contributes to this result, since most of the 
muscles attached to the long bones operate so much more energetically 
in the direction of their axes than in the direction of their diameters. 
Indeed, we have often seen these bones bent after complete fractures, 
and before the union was consummated, by muscular action alone. 

I repeat, then, that the gradual restoration of these bones is due to the 
same circumstance which produces at other times an immediate restora- 
tion, namely, the elasticity of the unbroken fibres, but which elasticity, 
in this latter instance, is, for a time, effectually resisted by the bracing 
of the broken fibres. At length, however, in consequence of the gradual 
absorption of the broken ends, the resistance is removed, and the bone 
becomes straight. If this absorption refuses to take place, and the fibres 
continue pressed forcibly against each other, as in the case described by 
Campaignac, then the bone remains permanently bent. 

Having straightened the bone as far as is practicable, it only remains 
to secure the fragments in place by suitable bandages or splints, [f the 
restoration is incomplete, these means may assist the efforts of nature in 
accomplishing a gradual restoration. 

It is scarcely necessary to say thai extension and counter-extension 
avail nothing in partial fractures. 

1 Trail-. Am. . viii.. 1855, pp. 892 5. 



108 BENDING, PARTIAL FRACTURES, AND FISSURES. 



§ 3. Fissures. 

These constitute the second principal form of incomplete fractures, or 
those in which the fracture is accompanied with no appreciable bending, 
which occur almost exclusively in inflexible bones, such as the compact 
bones of adults, and more often in the direction of their axes than of 
their diameters. They are complete so far as they extend, but they do 
not completely sever the bone so as to form two distinct fragments. 
They have been most frequently observed in the flat bones, such as the 
bones of the skull, and in the upper bones of the face ; occasionally in 
the long bones, both in their diaphyses and epiphyses, and rarely in the 
short bones. 

M. Grariel has reported, in the Bulletins de la Societe Anat., for 
1835, a case of fissure of the inferior maxilla, occurring in a lad sixteen 
or eighteen years old. Palletta found a fissure extending partly through 
the third dorsal vertebra, in a man who had fallen upon his back eleven 
days before ; and M. Lisfranc has mentioned a remarkable case of fissure 
and partial fracture, with bending of five ribs in the same person. 1 
Malgaigne believes that he has seen one example of this variety of in- 
complete fracture of the scapula, occurring through a portion of the in- 
fraspinous region. I have myself elsewhere recorded another, as having 
been found in the skeleton of Nimham, an Oneida Indian, who was a 
great fighter, and who died when about forty-five years old in conse- 
quence of severe injuries received in a street brawl ; but his death did 
not occur until four or five months after the receipt of the injuries. 

In addition to this fracture of the right scapula, five of his ribs were 
broken, and both legs, all of which, except the scapula, had united com- 
pletely by intermediate and ensheathing callus. 

The scapula was broken nearly transversely, the fracture commencing 
upon the posterior margin at a point about three-quarters of an inch 
below the spine, and extending across the body of the bone one inch 
and three-quarters, in a direction inclining a little upwards, being irregu- 
larly denticulate and without comminution. The fragments were in 
exact apposition, and, throughout most of their extent, in immediate 
contact. They were, however, not consolidated at any point, but upon 
either side of the fissure there was a ridge of ensheathing callus, of from 
one to three or four lines in breadth, and of half a line or less in thick- 
ness along the broken margin, from which point it subsided gradually 
to the level of the sound bone. The same was observed upon the inner 
as well as upon the outer surface of the scapula. The callus had as- 
sumed the character of complete bone, but it was more light and spongy 
than the natural tissue, and the outer surface had not yet become lamel- 
lated. Its blood-canals and bone-cells opened everywhere upon the 
surface. 

Directly over the fracture, and between its opposing edges, no callus 
existed, but as the bone had lain some time in the earth before it was 
exhumed, it is probable that a less completely organized intermediate 

1 Dea Fract. Incomplet. et des Fissures, par J. A. J. Campaignac, 1829, p. 20. 



FISSURES. 109 

callus had occupied this space, and that, owing to the less proportion of 
earthy matter, which it contained, it had become decomposed and had 
been removed. 

M. Yoillemier found the head of the humerus penetrated by two or 
three fissures: 1 and M. Campaignac has reported the case of a lad ten 
or twelve years old, who was compelled to submit to amputation of his 
arm at the shoulder-joint, in consequence of a severe injury, in which 
the humerus was found fissured from the insertion of the deltoid to near 
the condyles, extending through the entire thickness of the bone, and 
the edges of the fissure so much separated toward its lower extremity as 
to admit the blade of a knife. 2 Chaussier has related a case in which a 
criminal, who died soon after having submitted to the torture, was found 
to have a nearly longitudinal fissure of the radius in its upper fourth, 
and which penetrated half way through the thickness of the bone. 3 Gul- 
liver saw a fissure in the pelvis of an infant. 4 Malgaigne has seen two 
specimens of this fracture in the iliac bones, both of which belonged, as 
he thinks, to adults: in one, the fissure was limited to the internal table: 5 
and in the case of the lad reported by Gariel, as having a fissure of the 
inferior maxilla, there was also found a fissure of the left ilium, but 
which was limited to the outer table. 6 

M. J. Cloquet has mentioned a case of fissure of the shaft of the femur 
passing through the condyles and extending upwards to near the middle 
of the bone. The fissure was produced by a bullet, which had com- 
pletely traversed the bone from behind forwards, a little above the con- 
dyles." M. Malgaigne has also represented, in one of his plates, a 
fissure of the femur extending along the front of the bone, somewhat 
irregularly, from a point a little below the trochanter minor to near the 
condyles. 5 The bone was presented to the museum of Yal-de-Grace, by 
M. F leury : but it is to be regretted that we have no farther account of 
this remarkable specimen. Certainly in the complete absence of any 
farther history of the case, one might be justified in expressing a doubt 
whether it was not a fissure occasioned by the contraction consequent 
upon exposure, and drying after death. 

The following account of a fissure of the neck of the femur, of the 
same character with those which now occupy our attention, is copied 
from the proceedings of the "'Boston Society for Medical Improvement."' 
at its regular meeting in September, 18o< > : 

"Partial Fracture of the Seek of the Femur in a man cvt. 44 years. 
Specimen shown by Dr. Jackson. The fracture, which appears as a 
mere crack in the bone, commences anteriorly just above, but very near 
to the insertion of the capsular ligament, runs along the insertion for 
about an inch, anil then extends directly upward to the margin of the 
head of the bone. From this last point it crosses the upper surface of 
the neck almost in a straight line, and at a little distance from the mar- 

1 Malgaigne, op. cit., | 

2 Carnpaiirnuc Dea Fract. Incomplete etc., \>. "-'4. 

M ' L Legale, p. 447 •■• ' Gazette Med., p. 1885, p. 472. 

'■ Malgaigne, op eit., | 8 Bulletins de la Sue. Anat., 1885, p. 24. 

7 T\ <le Pathol. Externe. 1831. pi. xii. fig. 7. A- I >■ - I 

par Campaignac, ]*20. p. 10. 

Malgaigne, p. cit., p. 87, pi. 1 fi^. 1. 



110 BENDING, PARTIAL FRACTURES, AND FISSURES. 






-in of the head, but afterwards approaches very closely to this margin 
posteriorly: it then turns downward and obliquely forward, and stops at 
a point about halfway between the small trochanter and the head of 
the femur, and two-thirds of an inch or more anteriorly to the line of 
this trochanter. The fracture then involves about three-fourths of the 
neck of the bone; the inner anterior portion only being spared. There 
is considerable motion between the neck and the shaft, and the fracture 
could undoubtedly be completed without the application of any extraor- 
dinary force. Dr. J. referred to other cases of partial fracture; but a 
fracture of this sort, as occurring in this situation, and in a fully adult 
subject, he believed had never before been described, there was, also, 
in this case, a transverse fracture of the same femur midway, with a 
split extending upward nearly to the neck of the bone ; and still further, 
a fracture of the spine. The patient, a laboring man fell through two 
stories of a building and down upon a hard floor. On the same day he 
entered the Massachusetts General Hospital, and on the eighteenth day 
from the time of the accident he died. The femur is perfectly healthy 
in structure, and no changes are observable in the bone about the 
fracture." 1 

Whatever doubts may have been thrown upon the possibility of this 
accident, as applied to the neck of the femur, by the ingenious argu- 
ments of Robert Smith, of Dublin, 2 the question is now at least deter- 
mined by an incontestable fact. Dr. Smith had rendered it quite prob- 
able that both Colles and Adams were mistaken, and that the cases 
described by them were examples of impacted fracture, and not of par- 
tial fracture ; but in arguing the improbability of its occurrence, from 
the infrequency of fractures of the neck of the femur in early life, he 
overlooked the fact that there were two forms of incomplete fractures, 
and that it was only the "green-stick" fracture which belonged mostly 
to childhood, "fissures" being found most often in the bones of adults. 
Indeed, I think the example recorded by Tournel in the Archives de 
Midecine had already, so early as the year 1837, established the possi- 
bility of a "fissure" in the neck of the femur; although by Malgaigne 
this case has been mentioned as an example of that other variety of 
partial fractures which is almost peculiar to childhood, and in which the 
bones yield quite as much by bending as by breaking. But the man 
was eighty-five years old, and, having died three months and a half after 
the accident, a long crevice was found, extending nearly through the 
neck of the femur, partly within and partly without the capsule. 

I have seen, in Dr. Mutter's valuable collection of bones at Philadel- 
phia, a specimen of fissure of the trochanter major, which, it is believed, 
occasioned the death of the patient by haemorrhage. 

Gulliver says there is an example of a fissure in a patella belonging to 
the museum of the Edinburgh College of Surgeons, the fissure traversing 
its articular face only. 3 

1 Bost. Med. and Surg. Journ., vol. lv. p. 351. See also Araer. Journ. Med. Sci. 
for 1857, p. 306, with engraving; and Bigelow on Hip-joint, p. 137. 

2 Treatise on Fractures in the vicinitv of Joints, etc., by Robert Wm. Smith, 
Dublin, 1854, p. 44 et seq. 

3 Malgaigne, op. cit., p. 35. 



FISSURES. Ill 

The first example of a fissure of the tibia is recorded by Corn. Stalpart 
Yander-TViel. in 1867 : and indeed this is. according to Campaignac. the 
first exact observation of this species of fracture which our science pos- 
sesses, although its existence had been recognized by the most ancient 
authors. A servant had been kicked by a horse, and after a time, pain 
continuing in the limb, his surgeon, Dufoix, suspected a fissure of the 
tibia, and having cut down to the bone, a cure was soon effectc '. : 

In theDupuytren Museum, at Paris, there are two tibiae with linear 
fractures, one without history, and the other presented by MM. Marjolin 
and Rullier, "and which had been broken by a ball.'' 2 In the example 
related by Campaignac. a woman, having leaped from a second-story 
window, died immediately, and upon examination she was found to have 
three fissures in the upper portion of the left tibia, of which only one 
entered the articulation. 3 

Many examples of fissure from "perforating" gunshot wounds of the 
bone have been observed during the late war in this country, but as these 
examples belong peculiarly to military surgery, they will be discussed 
more at length in the chapter on gunshot fractures. 

Duverney saw a priest who had fallen and bruised the middle of his 
left leg. the swelling and pain consequent upon which were subdued 
after a few days. The patient believed himself cured, and acted accord- 
ingly. Suddenly, in the night, he was seized with an acute pain in the 
limb ; and on cutting down to the bone, a bloody serum escaped from 
between it and the periosteum, and the bone was discovered to be fissured 
longitudinally. Subsequently the tibia was trephined, but the fissure 
•lid not reach the marrow. He recovered completely in less than two 
months. 

The same writer mentions another case, in which a soldier received 
the kick of a horse in the middle of his left leg, which was followed im- 
mediately by great pain, and subsequently by much inflammation, and 
even gangrene of the skin. The wound, however, cicatrized kindly, but 
after three months he was seized suddenly with a severe pain in the limb, 
and after the trial of many remedies, resort was finally had to the knife, 
when the tibia was seen to be discolored and cracked longitudinally. 
On the following day, the bone was opened over the course of the fissure 
with a chisel and mallet, and the patient was at once relieved by the 
e of a yellowish and very offensive matter. At the next dressing 
the bone was opened more freely by several applications of the trephine, 
and an abscess was exposed in the centre of the bone. The patient 
finally recovered after about four months. 4 M. Campaignac saw, also, at 
the Hopital la Charite. the tibia of a woman, aet. 38 years, upon which 
were found four fissures, the report of which case is accompanied with ;i 
wood-cut illustration. 5 

Fissures may occur probably at all periods of life, but they are more 
frequently found in the bones of adults. Campaignac, however, men- 
tions a fissure of the humerus in a child ten or twelve years old, and 
Gulliver has seen a fissure in the pelvis of an infant. 

1 Campaignac, op. cit., p. 17. 2 Malgaigne, op. cit, ; 

.paiirnac, op. cit., p. 21. ; Ma -it., ]». '■'>'■' ct B€q. 

a nae, op. cit.. pp. '21 . 22. 



112 BENDING, PARTIAL FRACTURES, AND FISSURES. 

Etiology. — Fissures may be occasioned by most of those causes which 
produce fractures in general, such as direct or indirect shocks; but they 
are occasioned much more often by direct blows, especially when inflicted 
upon bones imperfectly covered by soft parts, such as the tibia. Bullets, 
having violently struck or penetrated the bone, have frequently occasioned 
fissures. 

Their course may be parallel with the axis of the bone, oblique, or 
transverse; they are often multiple; some merely enter the outer laminae, 
others open into the cellular tissue, and others still divide both surfaces 
of the bone through and through ; and, according as they penetrate more 
or less deeply the bone, their lips will be found to be more or less sep- 
arated. They frequently extend into the joint surfaces. 

Diagnosis. — The signs which indicate the existence of a fissure must, 
in a large majority of cases, be insufficient to determine fully the diag- 
nosis during the life of the patient. It is not probable that such fissures 
could ever be clearly made out by the touch alone, where the skin is not 
broken, since the pain, swelling, suppuration, etc., are only characteristic 
of inflammation of the bone or of its coverings, and might be equally 
present whether a fracture existed or not. In those rare cases only in 
which the flesh is torn off, and the surface of the bone is brought 
directly under the observation of the eve, will the diagnosis become 
certain. 

Treatment. — Fortunately, an error in judgment in this matter will 
not materially, if at all, prejudice the interests of the patient ; since, 
whatever may be the fact in other respects, if the bone, or its perios- 
teum, or its medullary tissue, is inflamed, and rest, with antiphlogistics, 
does not accomplish its speedy resolution, incisions and perforations 
become inevitable, if we would give either safety or relief to the sufferer. 
Accordingly, in the inflammation and suppuration consequent upon these 
fractures, we have seen that it has been occasionally found necessary to 
lay open the soft tissues freely, and even to trephine the bone at one or 
more points. 

Fissures in Cartilage. — I have once met with a fissure in the thyroid 
cartilage, which constitutes, so far as I know, the only example upon 
record of a fissure in cartilage. 1 

1 Bufl'alo Med. Journ., vol. xiii., article entitled Fracture of the Thyroid Cartilage. 



OSSA NASI. 113 



CHAPTER IX. 

FRACTURES OF THE NOSE. 

§ 1. Ossa Nasi. 

Of twenty-five cases of fracture of the ossa nasi recorded by me in 
my first edition, only fourteen were seen by a surgeon in time to afford 
relief. It seemed to me necessary, therefore, that the student should be 
instructed how frequently the nature of this accident is overlooked by 
the friends, and even by the surgeon himself, to the end that he might 
be thus admonished of the necessity of always instituting, in such cases, 
careful and thorough examinations. In some of the cases recorded in 
my notes, where surgeons were called in time, and a deformity remains, 
it is not improbable that the accident was not recognized. The rapidity 
with which swelling ensues after severe blows upon the nose, concealing 
at once the bones, and lifting the skin even above its natural level, ex- 
plains these mistakes. The nose, also, is remarkably sensitive, and the 
patient is often exceedingly reluctant to submit to a thorough examina- 
tion. It ought, however, not to be forgotten that the omission on the 
part of the surgeon to do his duty will not always be excused, even 
though the patient himself has protested against his interference, espe- 
cially where an organ so prominent, and so important to the harmony of 
the face, is the subject of his neglect or mal-adjustment ; since the most 
trivial deviation from its original form or position, even to the extent of 
one or two lines, becomes a serious deformity. 

When the ossa nasi are struck with considerable force, from before 
and from above, a transverse fracture occurs usually within from three 
to six lines of their lower and free margins, and the fragments are simply 
displaced backwards ; or if the blow is received partially upon one side, 
they are displaced more or less laterally. This is what will happen in a 
great majority of cases, as I have proved by examinations of the noses 
of those persons who have been the subjects of this accident, and by re- 
peated experiments upon the recent subject. 

These fragments are generally loose, and easily pressed back into 
place by the use of a proper instrument. A silver female catheter, 
which we have seen recommended by surgeons, may answer well enough 
in a few instances, but it will more often fail. The diameter of the 
meatus at the point where the instrument must touch in order to make 
effective pressure upon the ossa nasi, is on the average not more than 
two lines ; and when the membrane which lines it is injured, it becomes 
quickly swollen, and reduces the breadth of the channel to a line or less. 
Under these circumstances, any instrument of the size of a female 
catheter could only be made to reach and press against the nasal process 
of the superior maxilla, which is too firm and unyielding to allow it to 



114 FRACTURES OF THE NOSE. 

pass without the employment of unwarrantable force. In this way it 
happens that the operator is occasionally surprised to find how much 
resistance is opposed to his efforts to lift the bones, and, after repeated 
unsuccessful attempts, the case is not unfrequently given over. If, how- 
ever, he had used a smaller instrument, he would have found almost no 
resistance whatever. A straight steel director, or sound, or sometimes 
even a much smaller instrument, if possessing sufficient firmness, is more 
suitable than the catheter. For the same reason, also, one ought never 
to wrap the end of the instrument with a piece of cotton cloth, as some 
have, I suspect, without much consideration, recommended. 

What I have said of the facility with which these bones may be re- 
placed, when a proper instrument is employed, is true only when the 
treatment is adopted immediately, or at most within a few days after the 
accident. 

Boyer, Malgaigne, and others have noticed the fact that these frac- 
tures are repaired with great rapidity. Hippocrates thought the union 
was generally complete in six days ; and in a case which has come under 
my own observation, the fragments were quite firmly united on the 
seventh day. 

Nor has Malgaigne, whose observations are always very accurate, 
overlooked the fact, also, that their repair is effected without the inter- 
position of provisional callus, but as it were, "par premiere intention." 
My own observation confirms this statement. Among all the specimens 
which I have seen in the various college and private collections illus- 
trating fractures of the ossa nasi, and amounting in all to over forty, in 
no instance has there been detected, after a careful examination, the 
slightest trace of provisional callus. 

I am not certain that it will always be found so easy to retain these 
loose fragments in place, as it is to replace them. The very swelling 
which takes place so promptly under the skin tends to depress the frag- 
ments, unsupported as they are by any counter-force ; a tendency which, 
possibly, is in some instances increased by attempts on the part of the 
patient to clear his nostrils by snuffing and hawking. I have, in one 
instance, noticed very plainly a motion in the fragments when such 
efforts were made. How we are to remedy this, I am not prepared to 
say. None of the plans which I have seen suggested possess, in my 
estimation, very much practical value. Few patients will consent to the 
introduction of pledgets of lint, or of stuffed bags, or, indeed, of any- 
thing else, sufficiently far up into the nostrils to answer any useful pur- 
pose. The membrane is too sensitive and too intolerant of irritants to 
enable us to have recourse generally to such methods. Then, too, it 
would require, on the part of the surgeon, more than ordinary tact to 
accomplish so nice and delicate an adjustment of the supports from below 
as these cases demand, where the slightest excess of pressure, or the least 
fault in the position of the compress, must defeat the purpose of the 
operator. 

Yet, if one were disposed to make the attempt in certain cases where 
the comminution was very great, or where, for any other reason, the 
fragments would not remain in place, I think there could be no better 
plan than to push up in succession a number of small pledgets of sheet 



O S S A NASI. 



115 



lint, smeared -with simple cerate, to each one of which there has been 
attached «a separate string, so arranged that their relative position may 
he recognized, and that they may at a suitable time be removed in the 
order of their introduction. 

The employment of canulas. as recommended by Boyer, B. Bell, and 
others, allows of the nostrils being stuffed without interfering materially 
with the breathing: a provision, however, which is quite unnecessary 
with a majority of persons, so long as there exists no impediment to the 
free admission of air through the fauces. 

With nicely adjusted compresses made of soft cotton or lint, and secured 
upon the outside of the nose with delicate strips of adhesive plaster or 
rollers, we shall be better able to prevent the fragments from becoming 
displaced outwards than by moulds of wax, of lead, or of gutta percha, 
under which it is impossible to see from hour to hour what is transpiring. 

The complicated apparatus devised by Dubois and recommended by 
Malgaigne. to lift the bones and retain them in place, seems to me indeed 
very ingenious, but destitute of a single practical advantage. 

Supporting the fragments with a nickel-plated or gilded needle, which 
is made to transfix the nose at a point just below the fragments, was first 

Fig. 26. 




Mason's dressing. 

suggest by Dr. Lewis D. Mason. Surgeon to the Long Island College 
II apital, in 1880. 

Dr. Mason has. since this date, reported five cases treated by this 
method, three of which were treated by himself, and with highly satisfac- 
tory results. The pin i< removed on tic- eighth or tenth day, or as soon 
as the fragment- are sufficiently united nor to require support. I have 

1 Mason, Annals of the Anatomical and - iety of Brooklyn, March, 1880. 



116 FRACTURES OF THE NOSE. 

omitted to mention that a narrow strip of pure rubber bandage is to em- 
brace the ridge of the nose, to give additional support. 1 

.V more considerable force than that which I have first supposed will 
break, generally, the ossa nasi transversely and a little above their 
middle: while, at the same time, the nasal processes of the superior 
maxillary bones may suffer slightly. 

With neither of these accidents is the cribriform plate of the ethmoid 
likely to be broken or disturbed. Indeed, in numerous experiments 
made upon the recent subject, and in which the force of the blow was 
directed backwards and upwards, breaking and comminuting the nasal 
bones above and below their middle, with also the nasal processes of the 
superior maxillary bones, and the septum nasi, the cribriform plate of the 
ethmoid was. without an exception, uninjured. The exceeding tenuity 
and flexibility of the septum nasi at certain points prevents effectually 
the concussion from being communicated through it to the base of the 
brain. If, therefore, after these accidents, cerebral symptoms are occa- 
sionally present, as I have myself twice seen, 2 they must be due rather 
to the concussive effects of the blow upon the very summit of the nasal 
bones, where they rest immediately upon the nasal spine of the os frontis, 
or to some direct impression upon the skull itself. 

The amount of force requisite to break in the nasal bones, at their 
upper third, is very great ; no less, indeed, than is requisite to fracture 
the os frontis. If they do finally yield at this point, then no doubt the 
base of the skull must yield also. Nor do I think patients could often 
be expected to recover from an accident so severe. To this class of frac- 
tures belongs the specimen contained in my museum, in which not only 
both of the nasal bones are depressed — the nasal spine being broken at its 
base — but also the os frontis is depressed; the nasal processes of the 
upper maxillary bones are broken and greatly displaced, and the anterior 
half of the cribriform plate of the ethmoid is forced up into the base of 
the brain. If it is meant that in these cases the patient is in danger 
from injury done to the base of the skull through the fracture and depres- 
sion of the ossa nasi, we can appreciate the value of the opinion ; but we 
do not understand how this danger can exist when the nasal spine of the 
os frontis is not broken, and the upper ends of the nasal bones are not 
displaced backwards. But, admitting that it were possible in this way 
to force up the base of the skull, it does not seem to me that we ought to 
attach any value to the advice occasionally given, to attempt to restore 
the broken ethmoid by seizing upon the septum and pulling downwards. 
A force sufficient to break the base of the skull never fails to comminute 
and detach almost completely the septum nasi. "We are to proceed in 
such a case as we would in a case of broken skull. We must lay open 
the skin freely, and with appropriate instruments seek to elevate and 
remove, if necessary, the fragments. Indeed, after such accidents, we 
shall generally see plainly enough that death is inevitable, and that our 
services will be of no value. 

Occasionally, I have observed, the bones are neither broken at their 

1 Arner. Med. Digest. Jan. 1882. 

2 Report on Deformities after Fractures, Cases 16 and 18. 



OSS A NASI. 117 

lower ends nor through their central diameters, but only at their lateral, 
serrated, or imbricated margins. This is rather a displacement, or dislo- 
cation, than a fracture. It is more likely to happen. I think, in child- 
hood than in middle or old age. as in the following example: 

Thomas Keller, aged four years, was kicked by a horse. Two hours 
afterwards, when he was first seen by a surgeon, the nose and face were 
much swollen, and the fracture was overlooked. 

One year after the accident. I found both nasal bones depressed 
through nearly their whole length, and especially in the lower halves. 
The right nasal process was also much depressed, and the right nostril 
obstructed. The lachrymal canals upon this side were closed. 

Sometimes the lower ends of the nasal bones are bent backwards, or 
laterally, constituting a partial fracture. 

A lad. aged ten years, was hit by one of his mates accidentally with 
his elbow, upon the left side of his nose. I was immediately called, and 
found the lower end of the left os nasi displaced laterally and backwards, 
so that it rested under the lower end of the right os nasi. There did not 
appear to be any fracture beyond that which was inevitable by the mere 
separation of its serrated margins from the bone adjoining. The angle 
formed by the bone at the point where the bending had occurred was 
smooth and rounded, and not abrupt as in a complete fracture. 

With a steel instrument, introduced into the left nostril. I attempted 
to lift the bone to its place. The membrane was very sensitive, and the 
patient very restless under my repeated efforts. I pressed upwards with 
considerable force, and succeeded at length in bringing the bone nearly 
into position. 

If there is more complete displacement, the upper ends are not usually 
forced backwards, but rather a very little forwards, from their articula- 
tions with the os frontis, and the bones then swing, as it were, upon the 
lower ends of the nasal spine, as upon a pivot. In this condition they 
are very firmly locked, and it requires considerable force, applied under 
their lower extremities, to restore them to place. 

Such seemed to be the position of the bones in the case of the lad 
Kelley. already mentioned, and also in a German, whose nose was flat- 
tened by a severe blow when he was eleven years old, whom I saw, 
thirteen years after the accident, in the Buffalo Hospital. In this last 
example the bones were very much displaced backwards. 

In children, also, the nasal bones may be spread and flattened, the 
lateral margins not being depressed or displaced, but only the mesial line 
or arch forced back, so as to press aside the processes of the superior 
maxilla : which deformity may become permanent. 

A block of wood fell upon a child three week- "Id. a- she was lying 
in the cradle. The nature of the injury was not understood by the 
parents, and no surgeon was called. The ossa nasi are now. twelve 
year- after the accident, much wider than is natural, and depressed : the 
nasal processes of the superior maxilla appearing to have been spread 
asnnder. 

Jacob Kibbs, a Gorman, aged seven years, fell from a height of forty 
feet, striking on his face. His parents did not suspect the injury, and 
no surgeon was called. Twenty-four years after tin-. I found the nose 



US' FRACTURES OF THE NOSE. 

almost flat. The nasal bones appeared unusually wide, and were sunken 
between the processes of the upper maxillary bones, which latter might 
be recognized by two parallel ridges on each side, slightly rising above 
the level of the ossa nasi. 

Benjamin Bell and others have spoken of tedious ulcers, polypi, ne- 
crosis, fistula lachrymalis, abscesses, impeded respiration, and impairment 
of the sense of smell and of speech, as circumstances apt to result from 
these injuries, and it is certain that such consequences have occasionally 
followed ; but they must generally be regarded as accidents due to the 
state of the general system, and as having no connection with the frac- 
ture, except as this injury served to awaken certain vicious tendencies. 

A gentleman twenty-five years old was struck accidentally upon the right 
side of his nose by a board, and the ossa nasi were displaced to the left. 
A surgeon made an attempt to reduce them, but did not succeed, and 
they have remained displaced ever since. The nose for a time was much 
swollen. A few months after the accident, a purulent discharge com- 
menced from the right nostril, and at length an abscess formed in the 
right cheek. Two years later, when he came first under my notice, the 
nose still continued to discharge pus, and occasionally it bled freely. 
There was also a perforation of the septum, of the size of a three-cent 
piece, which had not ceased to enlarge. 

Xo hereditary maladies exist in the family, except that, on his father's 
side, it has been generally observed that wounds do not heal kindly. 
The same is the fact with him. When a child, he was also very subject 
to epistaxis ; at sixteen, a pulmonary difficulty began, and he had more 
or less cough, with haemoptysis, for two years. Since then his health 
has been good. He is a lawyer by profession, but of late he has lived 
in the country, upon a farm, and has accustomed himself to much out- 
door exercise. 

As to the prognosis in these fractures, I can only say that either owing 
to the ignorance and carelessness of the patients themselves, who neglect 
to call a surgeon in time, or to the difficulty of diagnosis, or to the 
greater difficulty in maintaining an adjustment of the fragments, it has 
hitherto happened that, after a fracture of the ossa nasi, more or less 
deformity has usually remained. I have seen but a few which could be 
said to be perfectly restored. 

§ 2. Fractures and Displacements of the Septum Narium. 

Fractures or displacements of the septum narium must occur to some 
extent in all fractures of the ossa nasi accompanied w T ith depression ; 
but they are also occasionally met with as the results of a blow upon the 
nose which has been insufficient to break the bones, and in which only 
the cartilaginous portion of the nose has been bent inwards upon the 
septum. 

Of these simple, uncomplicated accidents, I have seen eight ; in four 
of which no surgeon was employed, or surgical treatment of any kind 
adopted, and it is quite probable that only in a small proportion of all 
the eases was the nature of the accident recognized. Such, at least, has 



FRACTURES AND DISPLACEMENTS OF SEPTUM XARIUM. 119 

been generally the statement of the patients themselves. The same 
causes will explain this which have been invoked to explain similar over- 
sights in cases of broken ossa nasi. To which we may add, as an addi- 
tional reason why it may be overlooked, the frequency of lateral distor- 
tions or deviations in the natural development of this septum. 

The cartilaginous portion of the septum is that which is most fre- 
quently displaced by violence, and then it is usually at the point of its 
articulation with the bony septum. Next, in point of frequency, the 
perpendicular nasal plate is broken, and especially where it approaches 
the vomer. We omit in this enumeration, of course, those cases where 
the nasal bones themselves are broken down, in most or all of which, as 
we have already said, the perpendicular plate is more or less fractured 
and displaced. "We cannot say how often the vomer is broken, since it is 
beyond our observation, except in autopsies. It is probable, however, 
that the force of the concussion rarely reaches it, the cartilage or the 
perpendicular plate giving way first and easily. 

Where the deviation is only lateral, the results are less serious, yet 
sufficiently so. in a few instances, to demand our attention. Lateral 
obliquity of the lower portion of the nose follows generally, but not 
uniformly, a lateral displacement of the cartilage; and when it does 
exist, it is not always proportioned to the amount of displacement existing 
in the septum, so that the septum is then made to project obliquely across 
the nasal passage, causing often a serious obstruction and permanent 
inconvenience. In one instance, also, I have known it to occasion a 
chronic catarrh. 

A lad, aet. 15, was struck violently on the nose, which became imme- 
diately much swollen, but no surgeon was called. Eight years after I 
found the septum displaced laterally, and to the left side, producing also 
a slight lateral inclination of the end of the nose. He was unable to 
breathe freely through the left nostril, and from the same side a catarrhal 
discharge had continued from the time of the accident. 

The following example, in which the accident has been followed by a 
morbid condition of the cutaneous glands, is of more difficult explanation : 

A young man, ret. 23, called upon me, supposing that he had a poly- 
pus nasi. I found that in consequence of a fall upon the ice, seven years 
before, the septum nariuin had been displaced to the right so as almost 
completely to close this nostril. In very cold weather, when the vessels of 
the membrane are contracted, the passage is more free. The left nostril 
is proportionally wide. 

During the last four or five years, the right side of his face has been 
subject to profuse perspiration. It is almost constant in summer, and 
only occasional in winter. The line of division between the perspiring 
and non-perspiring portions of the face passes perpendicularly from the 
top of the centre of the forehead, along the ridge of the uose, and down 
to the centre of the chin. The phenomenon is due, perhaps, to an 
increased vascularity in the right side of the fare: possibly to some pecu- 
liarity in the condition of the nervous trunks, I by the oasal 
obstruction. 

A depression of the cartilage forming a portion of tin- ridge of the 
panied with a corresponding degree of lateral 



120 FRACTURES OF THE NOSE. 

displacement, with or without fracture, of its perpendicular portion, and 
produces, therefore, not only great deformity, sometimes a complete 
ilat toning of the end of the nose, but, also, in some instances, complete 
obstruction of the nostrils. 

We conclude, from all that we have seen, that fractures and displace- 
ments of the septum narium are generally followed by permanent de- 
formity, and occasionally with still more serious results. We suggest, 
therefore, a more careful examination in recent injuries, with a view 
to the ascertainment of its lesions, and it would be well, certainly, if we 
could devise some reliable mode of treatment. 

It is doubtful whether a partition so thin and unsupported can ever be 
■well adjusted and supported by artificial means. We possess, however, 
some advantages in the treatment of this accident which we do not in 
the treatment of broken ossa nasi, viz., facility of observation and of 
approach ; and if we can do little with plugs and supports in the one 
case, we may possibly do more in the other. Nothing seems more 
rational, then, than to plug carefully and equally each nostril with 
pledgets of lint, while we cover the outside of the nose completely with 
a nicely moulded gutta-percha splint or case, which ought to be made to 
press snugly upon the sides, and permitting these to remain for several 
weeks, or until the cure is completed. The papier mache of Dzondi, 
employed by him in cases of broken ossa nasi, would be equally applica- 
ble here ; but the gutta-percha, as being more plastic, and hardening 
more quickly, ought to be preferred. 

Attempts to remedy the deformities of the nose, at a later period, 
belong to the department of anaplastic surgery, and the modes of pro- 
cedure must be varied according to the circumstances of the case. 

The following example will serve as an illustration of what may some- 
times be accomplished in these cases: 

A young man fell from a two-story window, striking upon his face. 
A surgeon was called, but he did not discover the nature of the injury to 
the nose. 

One year after the accident he called upon me for relief. The car- 
tilaginous portion of the septum was broken just at the ends of the nasal 
bones, and forced backwards about three lines, producing a striking 
depression at this point of the ridge of the nose, whilst at the same time 
the end of the nose was thrown up. The deformity was very unseemly, 
and annoying both to himself and to his friends, who at first could scarcely 
recognize him. 

I introduced a narrow, sharp-pointed bistoury through the skin of the 
nose on the right side, and resting its edge upon the ridge at the junction 
of the cartilage with the ossa nasi, I cut the cartilaginous septum directly 
backwards about three lines, and then making a gradual curve with my 
knife, I cut downwards about eight lines toward the end of the nose. 
The intercepted portion of cartilage could now be easily lifted with a 
probe, and the line of the ridge of the nose completely restored. It was 
at once apparent, also, that lifting the cartilage would depress the tip of 
the nose and restore its symmetry. 

To retain the cartilage in place, I constructed a gutta-percha splint of 
the length and shape of the nose, but so formed along its middle as that 



FRACTURES OF THE MALAR BONE. 121 

it would not press upon the cartilage which I had lifted, resting well 
upon the ossa nasi, but not touching the ridge from the lower ends of 
these bones to the tip of the nose, at which latter point it again received 
support. I now passed a needle, armed with a stout ligature, through 
the upper end of the uplifted cartilage, transfixing, of course, the skin 
on both sides of the nose, and this I tied firmly over the splint. This 
accomplished the important object of pressing backAvards and downwards 
the tip of the nose, and thus tilting up the upper part of the ridge and 
septum, and of more effectually securing the cartilage in place by lifting- 
it directly with the ligature. On the second day the ligature was removed, 
but the splint was continued two weeks, during most of which time a 
band was kept drawn across the lower end of the splint, and tied behind 
the neck. 

To prevent the cartilage from falling back when final cicatrization 
occurred, I pressed the sides of the splint firmly toward each other, just 
below the incision, so as to force as much as possible the walls of the 
nares into the fissure of the septum, made by lifting it up. The result 
is a complete and perfect restoration of the nose to its original form. 

Dr. James Bolton, of Richmond, Va., has devised a very ingenious 
mode of rectifying an old displacement of the septum nasi. He makes 
a stellate incision of the septum in such a manner as to form of it about 
eight triangles with their apices converging to a common centre. He 
then seizes each triangle separately with a pair of forceps, and breaks it 
at its base without detaching it. Having thus comminuted the septum, 
he is able to restore it to position and retain it until consolidation is 
effected. 1 



CHAPTER X. 

FEACTURES OF THE MALAR BOXE. 

I have been unable to find any records of a simple fracture of the 
malar bone, that is to say, of a fracture unconnected with a fracture of 
other bones of the face. It is probable, however, that it sometimes 
occurs, but that, not being accompanied with much displacement, it is 
overlooked. I have myself seen a fracture of the upper margin, or of 
that portion which constitutes a part of the orbital border, in two or 
three instances, while I was unable to detect any other fracture among 
the bones of the face : but it is by no means certain that other fractures 
did not exist, perhaps in some of the bones which form the socket, or in 
the superior maxilla, as mere fissures, or as fractures with only Blighl 
displacement. The prominence of the malar bone, and especially the 
sharpness of its orbital margin, would enable the surgeon to detect easily 
the smallest displacement, or even a fissure, whilst a much more exten- 
sive displacement elsewhere would escape detection. 

1 Bolton, Richmond Med. Journ., April, 1868, ]>. 211. 



122 



FRACTURES OF THE MALAR BONE. 



The two upper maxillary bones form, as they are placed opposite to 
each other, an irregular arch, one end of which rests upon its fellow, at 
the intermaxillary suture, and the other end rests upon the nasal and 
frontal hones : whilst over the centre of the arch is situated the malar 
bone. The force of a side blow upon the malar bone will expend itself, 
therefore, chiefly upon the base of the maxillary apophysis, as being in 
the line of the direction of the force. The force continuing to act, after 
the apophysis is broken, the portion of the superior maxilla above the 
floor of the nares will fall inwards toward the septum, while the portion 
below will tilt outward, and open the intermaxillary suture along the 
roof of the mouth. This suture will also open more widely in front than 
behind, owing to the greater depth of the suture in front. 

These observations I have verified by several experiments made with 
a hammer upon a clean skull. 

One might suppose that it would be a very easy matter to restore 
these bones to place upon the naked skull, after such an accident. Cer- 
tainly it would be very desirable to do so, were this accident to occur to 
any patient, since the malar bone is slightly depressed, the nostril upon 
this side is nearly closed, and the line of the teeth is disturbed, and it is 
possible also that an opening might be established between the nose and 
mouth immediately back of the incisors. In fact, however, I found the 
restoration impossible. It could not be accomplished by an instrument 
within the nose pressing outwards, nor by pressing inwards upon the 
teeth and alveoli ; not, certainly, without very great and unwarrantable 
force. The difficulty consisted simply in the antagonism of the serrated 
margins of the intermaxillary suture, which, projecting one or two lines 
on each side, could not be made to interlock again, but were firmly 
braced against each other. 

I shall not find it necessary to report in detail the results of the ex- 
periments, but shall content myself with stating that by the second blow, 
in the last experiment, the skull was also found broken at its base, 
through the lesser wings of Ingrassias ; the force of the blow having 
been conveyed, apparently, along the orbital plate of the superior maxilla 
and os planum. 

This is the only example from four experiments in which the fracture 
extended through the dental arcade, and it was the result of the first 
blow. The fracture of the base of the skull by the second blow indicates 
the possibility of producing a fatal lesion of the brain or of its blood- 
vessels by a blow upon the malar bone. 

General Summary of results when the blow was inflicted directly 
upon the malar bone. — A fracture of the superior maxilla occurred in 
every instance : and twice when the malar bone was not broken : in each 
of the last two cases the antrum alone was broken, and the depression 
of the malar bone was scarcely noticeable. In the second of these cases, 
the fracture extended also through the dental arcade. 

In three cases the nasal apophysis was broken near the base, and in 
one case at two points. One of the three fractures of the nasal apophysis 
was accompanied with a diastasis of the superior maxilla through its 
intermaxillary suture. 

The malar bone has been broken twice by the first blow, and always 



FRACTURES OF THE MALAR BONE. 123 

when the blow has been repeated. The orbital margin and orbital plate 
have been fissured twice, the outer portion of the orbital plate being 
pushed a little into the socket. Once this plate has been pushed down- 
wards. 

The zygoma has been broken three times, and always transversely a 
little beyond its centre, or where the bone is the most slender and most 
convex. 

The ethmoid has been broken three times, and always longitudinally 
through the orbital plate. 

The sphenoid has been broken once, at the base of the skull. 

In addition to these observations upon the naked skull, I have seen at 
least four examples, which illustrate the relative infrequency of fractures 
of the malar bone, as compared with fractures of the superior maxilla and 
of the other bones of the face, even when the blow r is received directly 
upon the malar bone. 

Patrick Maloney, set. oo, fell about twenty feet and struck upon his 
face. Six weeks after the accident, while an inmate of the Buffalo 
Hospital of the Sisters of Charity, I found the right malar bone de- 
pressed, but I could not trace any line of fracture in the malar bone. 
I think the antrum of the superior maxilla was broken, and the malm- 
bone forced in upon it. 

Thomas Crotty, ret. 20, was struck with a hoop, August 15, 1855. 
He was seen immediately by a surgeon in Canada, but the fracture was 
not recognized. Five days after, he called at my office. I found the 
outer portion of the right malar bone lifted slightly, and the lower and 
anterior angle depressed about three lines, as if this portion had been 
forced in upon the antrum. 

The third case will be found reported under fractures of the superior 
maxilla, and the fourth has been brought under my notice in the practice 
of Dr. Wadsworth, of New York, the fracture having been occasioned by 
collision with the head of another man. 

Prognosis. — The malar bone may be depressed, as we have seen, to 
the extent of two or three lines, without being broken. This accident 
will be more properly considered under fractures of the upper maxilla. 
A fracture of the malar bone implies, therefore, generally, that great 
force has been applied, and that other fractures exist as complications. 
This may not be true, however, when only the orbital margin of the 
socket is broken. If the orbital plate is broken, and a portion of it is 
poshed into the socket, it may occasion a slight protrusion of the ball, 
as in two cases related by Dr. Neill as fractures of the upper maxilla. 
and as has been noticed in the experiments already referred to. This 
protrusion of the eyeball will probably continue, in some degree, as long 
as the bones remain displaced. It is quite probable, however, that in 
eases, after severe injuries of the face, a moderate protrusion of the 
eyeball is due entirely to extravasation of blood in the socket : a circum- 
stance which would be likely to follow a fracture of the bones of the 
socket, and to increase temporarily the protrusion of the eye. 

If the body of the bone is broken entirely through, and coma super- 
- upon the accident, there is aome reason to fear thai the skull is 
fractured at its base, and the prognosis ought to be grave. 



124 FRACTURES OF THE UPPER MAXILLARY BONES. 

Treatment. — If there is only a fissure of the orbital margin, it will not 
require attention : but if the fissure extends through the orbital plate, 
and at the same time the anterior and inferior margin of the bone is de- 
pressed, in consequence of which the orbital plate is tilted upwards and 
made to push forward the eyeball, the propriety of surgical interference 
may he considered. If this protrusion is considerable, and evidently due 
to the displaced bone, an attempt should be made to lift the body of the 
malar hone, and thus to restore to position its orbital plate. The method 
of accomplishing this I shall describe particularly when speaking of frac- 
tures of the superior maxilla with depression of the malar bones. 






CHAPTER XI. 

FKACTUPvES OF THE UPPEPv AtAXlLLAPvY BONES. 

These fractures assume so great a variety in respect to form, situation, 
and complications, that it would be impossible to speak of them systemati- 
cally, or to establish anything but very general rules as to treatment and 
prognosis. 

They may be broken, or loosened from each other or from the other 
bones with which they are articulated, with or without any farther frac- 
ture ; the nasal processes may be broken, and generally this accident is 
accompanied with a fracture of the nasal bones also ; the malar bones 
may be forced in, carrying with them a portion of the outer wall of the 
antrum; the alveoli may be broken and more or less completely de- 
tached ; and either of these several fractures may be complicated with 
fractures of the other bones of the face, or of the base of the skull even. 

Treatment. — When the harmonies of the upper maxillary bones are 
only slightly disturbed, nothing but a retentive treatment is necessary. 

A man was thrown backward from a loaded cart, one wheel of the 
cart passing over his face. He was taken up unconscious, but when 
I saw him on the following morning, his consciousness had returned. 
The right malar bone was broken, and forced down upon the antrum 
about three lines. Both superior maxillae were loosened from their 
articulations, and could be moved laterally, the motion producing a slight 
grating sound. The same motion and grating occurred whenever he 
attempted to swallow. No effort was made to elevate the malar bones, 
nor did I find any means necessary to retain the maxillary bones in 
place, the amount of displacement being very inconsiderable, and never 
sufficient to be observed by the eye. Cool lotions were applied constantly 
to the face, and the patient was sustained by a liquid diet. On the ninth 
day all motion of the fragments had ceased, and on the twenty-seventh 
day the patient was completely recovered, with only the depression of the 
malar bone remaining. 

Sargent, of Boston, reports a similar case, in which a slight separa- 



FRACTUEES OF THE UPPER MAXILLARY BOXES. 125 



Fig. 27 



tion of the maxillary bones united promptly and without any retentive 
apparatus. 1 

But in a ease in which the superior maxillary bones had been more 
completely torn from their connections, complicated with other severe 
injuries. I found it necessary to support the fragments by closing the 
lower jaw upon the upper, and by suitable bandages. The patient died, 
however, on the twelfth day. 2 

Graefe recommends, where the bones are thus extensively separated 
and displaced, an apparatus made of steel, and suitably covered, which 
is to be applied against the forehead and buckled under the occiput. 
From which apparel, in front, descend a couple of steel plates, which, 
having arrived at the free border of the upper lip, are reflected upon 
themselves, and are made to support upon their extremities long silver 
gutters, intended for the reception of not only the displaced teeth and 
alveoli, but also those teeth which are firm. 3 

Goffres has employed a similar apparatus, only that he has substituted 
gutta-percha for the silver gutters of Graefe. 4 In Goffres's case the appa- 
ratus was made to support a pad also, intended to make lateral pressure 
over the displaced fragments. 

Xo doubt cases may now and then occur in which this apparatus would 
serve a useful purpose ; but in most cases two interdental splints of gutta 
percha. placed one on either side, leav- 
ing an open interval in front for the pur- 
pose of conveying food to the stomach, 
will accomplish every indication, and 
in a manner much more comfortable 
to the patient, and more satisfactory 
to the surgeon, than any form of me- 
chanical apparatus. A pad or com- 
press upon the side of the face, sup- 
ported by a roller, is better than the 
pad attached to one side of Goffres 's 
apparatus, as a means of lateral sup- 
port. The mode of preparing and of 
applying gutta percha as an interdental 
splint, will be described in connection 
with fractures of the lower jaw. 

AVi>eman, having been summoned to 
a child with his whole upper jaw forced 
in by the kick of a horse, "beating the 
ethmoides quite in from the os cribri- 
forme," and forcing the palate bone 
against the back of the pharynx, found 
great difficulty in securing a perma- 
nent readjustment. At first lie attempted to introduce hifl finger buck 
of the bone: but. failing in this, he bent an instrument into the form of 




Goffres's modification of Graefe's 
apparatus. 



1 Boston Med. and Sunr- Journ., vol. lii. p. 37*. 

- Report on Deforrniti^ after Fracture. Trans. Amer. Med. Association, vol. viii. 

p. 375. Case IV. 

3 Traite des Frac, etc.. par L. P. Malgaigne, p 

* Goffres, Bullet, de l'Acad. de Med . 1862, t. 27, ]>. 11"<7 ; from Poinsot. 



126 FRACTURES OF THE UPPER MAXILLARY BONES. 

a hook, and, passing it between the bone and the pharynx, he easily 
replaced the fragments. But, on removing the instrument, they were 
again displaced. Immediately he had constructed an instrument by 
which the bones could be not only easily reduced, but also retained in 
place, extension being made by the hands of the child, his mother, and 
others, alternately. In this way the reunion was finally effected, and 
"the face restored to a good shape, better than could have been hoped 
for." 1 

Harris, of New York, mentions a case in which a child, two years 
old, having fallen from a height of fifty feet upon the pavement, was 
found to have a diastasis of both the superior maxillary and palate 
bones; the separation being sufficient to admit the little finger, and 
extending from between the alveoli which supported the central incisors, 
to the soft palate. It is not said whether any efforts w T ere made to reduce 
the bones, but six weeks after the injury was received they were still 
open, and it was proposed to close the space by a plastic operation as 
soon as the condition of the patient would warrant such a procedure. 2 

I suspect that in this example, as in my experiments referred to under 
fracture of the malar bone, it was found impossible to adjust the bones 
and close the intermaxillary suture, and for the same reasons. 

If, in consequence of a blow received upon the ossa nasi, the nasal 
processes of the superior maxillae are broken down, they may be lifted 
and adjusted in the same manner as the ossa nasi. 

I have seen several examples of this accident, and I have in my cabinet 
a specimen, in which the nasal bones being driven in by the kick of a 
horse, the nasal process upon the left side is broken off just above the 
root of the cuspid tooth, and its upper end inclined inwards towards the 
nasal passage and backwards, until it is completely buried. In this situ- 
ation it has become firmly united to the bony and soft tissues into which 
it was brought in contact. 

The following example will illustrate some of the complications and 
difficulties connected with a depression of the malar bone, and consequent 
fracture of the antrum maxillare. 

M. P., of Coles ville, aged about 34 years, was thrown from a height, 
striking upon his face, forcing the right malar bone down upon the antrum 
of the superior maxilla. Dr. L. Potter, of Varysburg, and myself were 
called. 

The deformity produced by the sinking of the malar bone was very 
striking, and both the patient and myself were very anxious to have it 
remedied, if possible. We found some of the teeth upon the side of the 
fracture loose, and we determined to extract them, and press up the bone 
with an instrument introduced through the empty sockets. The first 
attempt to extract a molar tooth, however, brought down several teeth, 
and the whole floor of the antrum. The detachment of this fragment 
was also now so complete that we believed it necessary to remove it 
entirely, a labor which was accomplished with infinite difficulty, and with 
no little hazard to the patient, as dissection had to be extended very far 

1 Chirurgical Treatises, by Kichard Wiseman, 1734, p. 443. 

2 New York Journ. Med., vol. xiii., 2d ser., p. 214. 



FRACTURES OF THE UPPER MAXILLARY BONES. 127 

back into the throat, and in the end it was not effected without bringing 
out. attached to the fragment of maxillary bone, a considerable portion of 
the pyramidal process of the os palati. 

The time occupied in this operation was at least one hour, during 
which we were every moment in the most painful apprehensions, lest we 
should reach and wound the internal carotid, which lay in such close 
juxtaposition to the knife that we could distinctly feel its pulsation. 
After its removal the haemorrhage was for an hour or more quite profuse, 
and could only be restrained by sponge compresses pressed firmly back 
into the mouth and antrum. 

When the haemorrhage was sufficiently controlled, we proceeded to ex- 
amine the antrum, the floor of which being removed entire, permitted 
the finger to enter freely. The restoration of the malar bone was now 
accomplished without much difficulty, and with only moderate force. 

Two years after the accident the face presented, externally, no traces 
of the original injury. The malar bone seemed to be as prominent as 
upon the opposite side, and there was no perceptible falling in where the 
teeth and alveoli were removed. During several months after the removal 
of the bone, the antrum continued to discharge pus, but at length a semi- 
cartilaginous structure closed in the cavity below, entirely reconstructing 
its floor, and the discharge ceased. Since then he has experienced no 
further inconvenience. 

I wish to propose two or three expedients for lifting the malar bone 
when it has been thrust down, which may in certain cases be substituted 
for the mode which has been heretofore generally adopted. 

In many instances no difficulty will be experienced in resorting to the 
usual method. The recent loss of one or more teeth opposite the floor 
of the broken antrum, or the complete displacement of a tooth by the 
accident itself, will give an opportunity for the perforation of the antrum 
through the open socket, and for the introduction of a suitable instrument 
for lifting the depressed bone. Unless, however, the opening is quite 
large, the instrument employed must be so small, such as a straight steel 
sound or a female catheter, as to expose the parts against which its end 
is made to press, to some risk of being broken and penetrated. It is 
even possible in this way to penetrate the socket of the eye, and thus 
inflict serious injury upon the eye itself. Yet, with some care, such 
accidents may be avoided, and it is probable that in the cases supposed, 
where the sockets of the teeth opposite the base of the antrum are open. 
this method will continue to have the preference. 

But if the teeth remain firm in their places, or if they have been some 
time removed, and the sockets are filled up, and we wish to enter the 
antrum at its base, we must either drill through its anterior wall above 
the roots of the teeth, or we must proceed to extract a tooth. The firsl 
method gives an inconvenient opening, and one through which it will be 
necessary to use a curved instrument; but yet it is a method far less 
objectionable than the extraction of a tooth which Is (inn. or which is 
even tolerably firm, in its socket, and which may require the forceps for 
its removal. The objections to this latter procedure were suggested by 
the tedious and painful operation already detailed. The first attempt to 
extract a tooth brought down the whole floor of the antrum, with nil its 



128 FRACTURES OF THE UPPER MAXILLARY BONES. 

corresponding teeth, and the pyramidal process of the palate bone. The 
tooth was already loose, and we thought it might easily be taken out, 
but it had not occurred to us that it was loosened by the comminuted 
condition of the walls of the antrum, and of the dental arcade. The ex- 
periments made upon the dead subject would seem to show that this frac- 
ture and comminution of the alveoli is not a very frequent result of a 
fracture of the antrum produced by a blow upon the malar bone ; yet it 
may happen, and whenever it does, the attempt to extract a tooth must 
always expose the patient to the same hazards. Certainly it is no trifling 
matter to pull away all of a man's upper teeth upon one side, and to 
open freely into a broad cavity which might never close again, and which, 
in this event, must always serve as a place of lodgement for particles of 
food, and for foul secretions, to say nothing of the external deformity 
which it is likely to produce, and of the severity and even danger of the 
operation. 

I wish, then, to suggest certain procedures, the value of which I have 
been able to determine by experiment upon the living subject in two or 
three cases, and which I have carefully and frequently tested upon the 
cadaver. 

First, we ought to attempt to lift the bone by putting the thumb under 
its zygomatic process and body within the mouth. If the bone is thrown 
directly downwards, or downwards and backwards, this method can 
scarcely fail ; and even when it is thrown downwards and forwards, so 
as to press into the antrum, it is likely to succeed. If, however, for any 
reason, the thumb cannot be brought to bear upon its under surface, we 
may make a small incision upon the cheek over the anterior margin of 
the masseter muscle, where its insertion into the malar bone terminates, 
and pushing a strong blunt hook under the bone, we may lift it with ease. 

Where the depression of the malar bone is in the direction of the an- 
terior and superior angle, these means may not be found available, and 
we may then employ a screw elevator, an instrument which I find already 
constructed in a case of trephining instruments made for me by Luer, 
of Paris, and which I have often used, and constantly recommended 
to my pupils, in certain cases of fractures of the skull. The instrument 
ought to be made of the best steel, and with a broad, sharp-cutting 
thread. A slight incision being made through the skin, and down to the 
centre of the malar bone, the elevator is then screwed firmly into its 
structure, and now its elevation and adjustment may be accomplished 
with the greatest ease. 

Malgaigne remarks : " In all complicated fractures of the upper jaw, 
there is one principle which surgeons cannot too much study, namely, 
that all fragments, however slightly adherent they may be, ought to be 
most carefully preserved, and they will be found to unite with wonderful 
ease. This remark had already been made by Saviard, Larrey insists 
strongly upon it, and we have seen that M. Baudens, so great an advo- 
cate for the removal of loose fragments, has declared for these fragments 
a special exemption." 1 

Malgaigne has here especial reference to fractures of the dental arcade,. 

1 Op. cit., vol. i. p. 376, Paris ed. 



FRACTURES OF THE UPPER MAXILLARY BONES. 129 

and to fractures implicating the alveoli, and extending more or less into 
the body of the bone. 

It would be an error, however, to suppose that a reunion will in these 
cases uniformly take place. Exceptions have occurred in my own prac- 
tice, the fragments becoming loosened and completely detached after the 
lapse of several weeks. In the case related by Miller, the whole floor 
of the antrum having been broken off, in an unskilful attempt to extract 
the second right upper molar, it was found impossible to make it unite, 
and it was subsequently removed. 1 Such unfortunate results certainly 
may sometimes be reasonably anticipated. Yet they occur so seldom as 
to justify the opinions and practice advocated by Malgaigne. 

In some instances, where fragments are displaced, carrying with them 
several teeth, while others in the same row remain firm, it will be suffi- 
cient to close the mouth and apply a bandage as for fracture of the infe- 
rior maxilla : in others, the teeth and their alveoli ought to be fastened 
with silk, or gold or silver thread ; gold, silver, gutta-percha, or vulcanite 
clasps may be applied to the teeth and jaw. 

In a case of fracture of the right superior maxilla, reported by Baker, 
of Norwich, X. Y., complicated with a fracture of the inferior maxilla, 
the alveoli were retained in place very perfectly by a mould of gutta 
percha. 2 Xeill. of Philadelphia, has also reported three cases of frac- 
ture of the bones of the face, involving the superior maxilla, in two of 
which the eyes were made to protrude more or less from their sockets. 
The loosened alveoli were made fast by wire. The subsequent deformity 
was inconsiderable, yet in no instance was the restoration complete. 3 
The same method was adopted successfully by a surgeon in Virginia, in 
the case of a negro fifty years old, where most of the teeth of the left 
upper jaw were forced into the mouth, carrying with them their corre- 
sponding alveolar processes. The teeth remained firm in their sockets, 
but the separation of the bone was complete, the fragment being held in 
place only by the mucous membrane of the mouth. On the eighth day 
the surgeon found that the negro had removed the wire, and also the cork 
from between his teeth, and the maxillary bandage ; but the soft parts 
had already united, and the bones showed no tendency to displacement. 
His recovery was speedy, and it was accomplished without any further 
treatment. 4 

Our experience during the war of the rebellion in this country con- 
firms most of the observations heretofore made in relation to these frac- 
tures. Owing to the extreme vascularity of the bones composing the upper 
jaw. the fragments have been found to unite, after the most severe gun- 
shot injuries, with surprising rapidity; the amount of necrosis and caries 
being usually inconsiderable, compared with the amount of comminution. 
The same anatomical circumstance, namely, the vascularity, has rendered 
these accidents peculiarly liable to troublesome haemorrhages, both primary 
and secondary. 

1 Miller, News Letter, April, 1854. Also, Boat Med. and Surg. Journ., vol. li. 

L 

2 Baker. New York Journ. of Med., vol. i., 3d ser., | 
Neill, Phil. Med. Exam., vol. x., new Bex . pp. 155-8. 

4 Anjer. Med. Gazette, vol. viii., new ser., p. 106. 






130 FRACTURES OF THE ZYGOMATIC ARCH. 

The Surgeon-General reports that of 4167 wounds of the face, tran- 
scribed from the reports from the beginning of the war to October, 1864, 
there were 1579 fractures of the facial bones, and of these 891 recovered, 
107 died — the terminations are still to be ascertained in 581 cases. He 
further remarks that secondary haemorrhage has been the principal source 
of fatality in these cases, and that frequent recourse has been had to 
ligation of the carotid, with the result of postponing for a time the fatal 
event. 1 



CHAPTER XII. 

EKACTUBES OF THE ZYGOMATIC ARCH. 

The zygoma, strictly speaking, is formed in a great measure by the 
body of the malar bone, and it is broken whenever the malar bone is 
completely separated through any portion of its body ; but I propose to 
confine my remarks to that portion only which is composed of the two 
processes, called respectively the zygomatic processes of the malar and 
temporal bone. 

Duverney relates a case in which a young child, having in his mouth 
the end of a lace-spindle, fell forwards and thrust the spindle through 
the mouth from within outwards, breaking the zygoma in the same direc- 
tion, and leaving the fragments salient outwards. 2 To which case of 
outward displacement Packard, in a note to Malgaigne's work on frac- 
tures, etc., has added a second. 3 

I know of no other examples in which the fragments have been thrust 
outAvards. A reference to my experiments upon the naked skull will, 
however, show that the zygoma may be broken and displaced in the same 
direction, by any force which shall fracture the superior maxilla, and 
depress the anterior margin of the malar bone. In my experiments this 
has happened three times, and always at the same point, viz., a little 
beyond the middle of the zygoma, near where the suture which joins the 
two processes terminates below. The fractures were always transverse, 
and not in the line of the suture. They were therefore fractures of that 
portion of the zygoma which belongs to the temporal bone. 

1 suspect, also, that to this class of cases belongs the example related 
by Dupuytren, in which the patient having died on the fifth day, from 
the effects of the cerebral concussion, the autopsy disclosed " a fracture 
through the zygomatic arch ; and that part of the superior maxillary 
bone which constitutes the antrum was driven in." 4 

In another case mentioned by Dupuytren, produced by a direct blow, 

» Circular No. 6, Washington, Nov. 1, 1865, p. 20. 

2 Duverney, Bulletin de la Societe Anatomique, p. 138, 1810. 
'■ Malgaigne, Amer. ed., p. 289, vol. i. 

4 Injuries and Diseases of Bones, by Baron Dupuvtren. Svd. ed., London, 1847, 
p. 336. 



FRACTURES OF THE ZYGOMATIC ARCH. 131 

the fracture was compound and comminuted, and although the fragments 
were raised easily by an elevator, suppuration ensued beneath, and the 
matter was discharged within the mouth. 1 

Tavignot reports a case of fracture of this arch which was not dis- 
covered until after death, the fragments not being at all displaced. 2 

Dr. John Boardman, one of the surgeons to the Buffalo Hospital of 
the Sisters of Charity, informs me that he has met with a fracture of 
the zygoma in a man about thirty years of age, occasioned by a blow 
from a cricket-ball. Dr. Boardman saw him on the fourth day, and 
ascertained that immediately on the receipt of the injury he felt slightly 
stunned, and that he soon recovered from this, but was unable to open 
his mouth except by pulling it open with his hand ; neither could he 
close it except in the same manner. This immobility of the jaw con- 
tinued several days with only very slight improvement ; at the end of 
five weeks, however, when last seen, the mobility was nearly, but not 
quite restored. The depression, a little in front of the centre of the 
zygoma, was discovered by the patient himself immediately after the 
receipt of the injury, and he says he tried at once to ascertain whether 
he could not push the fragments back by moving the jaw. He was 
unable to make any impression upon them by this manoeuvre. The 
depression still remains, but it is not so distinct as it was when first seen. 

Barney Quinn presented himself at the Bellevue Dispensary, April IT, 
1871, stating that he had been hit by a stone, in blasting, three weeks 
before. There was a fracture, with depression, at or near the junction 
of the malar and temporal processes. The malar bone was elevated a 
little. From the time of the accident he had been unable to open his 
mouth more than half an inch. 

January 2. 1874, Anna McQuirk fell upon the side of her face. 
Seven days after the accident she consulted me. There was a fracture 
with depression at the junction of the malar bone with, the zygoma. At 
first, and for a day or two. she could open and close her mouth easily, 
but when I saw her, the act of opening the mouth was painful and diffi- 
cult. Having introduced my fingers into the mouth. I attempted to press 
the fragment out. but was unable to make any impression upon it. 

It is plain that in this latter case the inability to open the mouth was 
due to the inflammation resulting from the injury, and not to the dis- 
placement of the bone, and that as the inflammation subsided the disa- 
bility would disappear. 

John Crandall, an adult, fell upon a stone February 21, 1875, striking 
upon the side of his face and head. He was stunned by the accident. 
On the following morning he could not open his mouth. Five week- 
later I found the zygoma much depressed near its junction with the malar 
bone, the corresponding edge of the malar bone being a little lifted. 
There had been a gradual improvement in his ability to open his mouth, 
and he could now separate the teeth about half an inch. I advised him 
that he might expect a slow but complete restoration of the use of hifl 
jaw: and if this did not occur within a few month-, to call upon me 

1 Op. cit.. | 2 Tavignot, Bulletin d it., 1810, p. 



132 FRACTUKES OF THE ZYGOMATIC ARCH. 

again, and I would lift the fragments; but, as lie has not returned, I 
infer that he recovered the use of his jaw. 

Symptoms. — An irregular projection or depression of the fragments 
is the only sign which can be relied upon to indicate the existence of this 
accident: and this must often be concealed by the swelling which follows 
so rapidly wherever the integuments are severely bruised over a super- 
ficial bone. This displacement can scarcely occur in but two directions, 
either outwards or inwards; since the attachments of the temporal aponeu- 
rosis above, and of the masseter muscle below, must effectually prevent 
its descent or ascent. 

Neither motion nor crepitus will often be present. In some cases the 
difficulty in opening or shutting the mouth, occasioned by the projection 
of the fragments toward or into the tendon of the temporal muscle, or by 
the inflammatory effusions, may assist in the diagnosis. 

Prognosis. — If the fracture has been produced indirectly by a depres- 
sion of the malar bone, the prognosis must depend upon the amount of 
injury done to the other bones of the face; in itself, the fracture of the 
zygoma cannot be a matter of any moment. The same remark might 
apply also to any fracture of the zygoma in which the angles were salient 
outwards. If, on the contrary, the angle is salient inwards, the fracture 
having been produced by a blow inflicted directly upon the zygomatic 
arch from without, or by a blow upon the outer portion of the malar 
bone, it may occasion some embarrassment to the action of the temporal 
muscles. 

If the force which produces the fracture has acted more upon the tem- 
poral portion of the arch, near where the process arises from the temporal 
bone, it may be accompanied with a fracture of the skull, and with serious 
cerebral lesions, as in one of the cases already alluded to as having been 
noticed by Dupuytren. 

The abscess which followed in the case of the compound, comminuted 
fracture, quoted from the same author, indicates the danger of this com- 
plication ; but it must be noticed that its evacuation resulted in a rapid 
cure, and that no deformity or difficulty in moving the jaw remained. 

Treatment. — A fracture, accompanied with an outward displacement, 
and occasioned by a depression of the malar bone, will be adjusted by 
a restoration of the malar bone in the manner already described, when 
speaking of fractures of the superior maxilla, etc. If the fragments are 
displaced outwards, in consequence of a direct blow from within, then 
they may be replaced by pressing upon the projecting angle. In this 
way Duverney easily reduced the bones in the case which I have cited. 

When the fragments, in consequence of a direct blow from without, • 
have been driven inwards, and, as a consequence, serious embarrassment 
to the motions of the temporal muscle ensues, an attempt ought to be 
made at once to replace them; if, however, no impediment to the action 
of the muscle exists, it is scarcely necessary to say that no surgical 
interference will be required. It is quite probable, indeed, that a slight 
amount of embarrassment may be the result of the direct injury to the 
muscle inflicted by the blow, without reference to the displacement of 
the bone, and that a few days will suffice to remedy this evil entirely; 
and. moreover, experience teaches that in the case of a fracture in other 



FRACTURES OF THE LOWER JAW. 133 

bones, where the fragments actually penetrate the muscles and remain 
thus displaced, the points are gradually absorbed, ami rounded, 80 that 
after a time they constitute no impediment to the action of the muscles. 
It is proper to infer that the same thing will occur here. The surgeon 
mav be reminded, also, that it is not the muscle, but its tendon, which is 
liable to be penetrated: and that this is usually protected somewhat by 
a plate of soft adipose tissue lying between the tendon and the arch. 

If to these considerations we add the difficulties which we shall be 
likely to encounter in the reduction, we shall expect to find but few cases 
in which a resort to surgical interference will be necessary. 

Duverney says that he restored a fracture of this arch, accompanied 
with depression, by pressing against the zj'goma from within the mouth : 
but an examination of the interior of the buccal cavity will convince us 
that this is impossible when the fracture is at any point near the middle 
of the zygoma : and that it can be only when the fracture is at or near 
the junction of the zygoma with the body of the malar bone, that any 
effective pressure can be made from this direction. In such a case we 
may. perhaps, lift the portion of the zygoma remaining attached to the 
malar bone, by the same means which have already been suggested for 
lifting the bone itself. 

If the bone is driven toward the tendon of the temporal muscle at or 
near its centre, and if its restoration becomes necessary, it can be accom- 
plished only by approaching the bone from without. 

Dupuytren found an external wound through which, by the aid of a 
levator, he easily restored the fragments to place. 

M. Ferrier. however, of the Hospital of Aries, in a case brought before 
him. made an incision through the integuments down to the bone, and 
then attempted to slide underneath the small extremity of a spatula ; but 
the aponeurosis would not yield, and he was obliged to cut it also. He 
was now able to lift the fragments easily. The wound healed rapidly. 
and the patient was dismissed without any deformity. 1 



CHAPTER XIII. 
FKACTTTRES OF THE LOW Kit JAW. 

"Division. — Of 55 example- of fracture of this bone which have hern 
recorded by me. not including gunshot fractures. 52 were broken 
through some portion of the body. 

Having made an analysis of 45 of the above examples, 1 find that M 
were broken completely asunder at two or more points, constituting 
double and triple fractures : and of the remainder, 5 were accompanied 
with detachment of portions of the alveoli, and one with detachmenl of 
a considerable fragment from tie- body. 

] Ferrier, Bulletii § M '■'.. torn. x. \>. !»;<>. 



134 



FRACTURES OF THE LOWER JAW. 



Fig. 28. 




13 were compound; not including in this enumeration several examples 
in which the partial or complete dislodgement of a tooth might entitle 
thorn to be (.-ailed compound. 

Four fractures through or near the symphysis were nearly or quite ver- 
tical, and most of the others were known to be oblique. Malgaigne has 

remarked, also, that in fractures of the 
body of the bone the direction of the 
obliquity is generally such that the 
anterior fragment is made at the ex- 
pense of the internal face of the bone, 
and the posterior fragment at the ex- 
pense of the external face, this latter 
overriding the former. Buck, of New 
York, has seen the fragments in an 
opposite condition, requiring the use 
of the knife and saw for their extri- 
cation. 1 I have myself recorded one 
similar example, but in which the fragments were easily replaced. 

In 30 examples of fractures through the body, not including fractures 
of the symphysis, the line of fracture has been observed to be 20 times 
at or very near the mental foramen, 3 times between the first and 
second incisors, 4 times behind the last molar, and 3 times between the 
last two molars. 

Syme, Liston, and Miller have remarked, also, the greater frequency 
of fracture near the anterior mental foramen; but Mr. Erichsen thinks 
he has seen it most frequently broken near the symphysis, between the 
lateral incisors, or between these teeth and the canine. Boyer observes 
that it is generally somewhat in front of the foramen; for which reason, 
as he thinks, the dental nerve is rarely torn. 

Says Boyer, in his Traite des Maladies Chirurgicales, "A fracture 
never takes place in the central point of the length of the jaw, called the 
symphysis of the chin ; but when the solution of continuity occurs toward 
the middle of the bone, it is upon one or the other side of the symphysis, 
which remains always upon one of the fragments;" an opinion which, 
however, he does not seem always to have entertained, since Richerand, 
in a report of his lectures, has made him say that a fracture sometimes 
takes place "near the chin, but seldom so as to produce the division of the 
symphysis of that part, though it be not impossible." But many surgeons 
since his time have noticed this fracture, and Malgaigne assures us that 
J. Cloquet has demonstrated its existence upon an anatomical specimen. 
Stephen Smith, of New York, has seen two examples; 2 Lonsdale men- 
tions three; 3 and Gibson has seen one; 4 and I have met with two, both 
of which are recorded in the early editions of this book. 

Velpeau, Fergusson, Gibson, Henry Smith, and others, have remarked 



1 Buck, New York Journ. Mod., March, 1847. Proceedings of N. Y. Med. and 
Surg. Soc, Sept. 19, 1846. 

2 Smith, New York Journ. Med., Jan. 1857, Hospital Keports. 

3 Practical Treatise on Fractures. By Edward F. Lonsdale, London, 1838, p. 226. 

4 Institutes and Practice of Surgery. By William Gibson. Philadelphia, 1841, 
]». -J.il. 



FRACTURES OF THE LOWER JAW. 135 

that a separation at the symphysis takes place usually in infancy or child- 
hood. But in the eight examples in which I find the ages reported, only 
one. a case mentioned by Lonsdale, occurred in a person as young as 
ten years: in one of the cases seen by myself, the patient was seventeen 
years old. and the remainder have ranged from twenty-five years to sixty; 
and the average age of all is thirty-two years. 

I have seen one example of a fracture of the ramus, in a man twenty- 
three years old. who had been struck by a wooden block on the side of 
his face. The ramus was broken just above the angle, and the body 
was broken, also, obliquely near the symphysis. The intercepted frag- 
ment was carried inwards; 1 and in May, 1869, I met with another 
similar case at Bellevue Hospital, in a woman ; a pharyngeal abscess re- 
sulted, threatening suffocation : for which my house surgeon, Dr. Francke 
Bosworth. performed tracheotomy successfully. Ledran mentions the 
case of a child, ten or twelve years old, in whom the fracture was double 
also : one fracture having taken place through the body, and one extend- 
ing obliquely from the root of the coronoid process to the neck of the con- 
dyle. The intercepted fragment was, however, so little displaced that 
the fracture of the ramus was not discovered until after death. 2 Mal- 
gaigne refers to this as the only example recorded; but Stephen Smith, 
of the Bellevue Hospital, has met with it four times: in one case the 
ramus was broken on both sides : in two cases one ramus only was broken ; 
and in one the body was broken on the right side and the ramus on the 
left. 3 In two of these examples the fragments were not displaced. 

The coronoid process is so well protected by muscles and by the sur- 
rounding bony projections, that it is very rarely broken. 

Houzelot mentions a case in which a fall from a "height produced at 
the same time a fracture of both condyles, of both coronoid processes, 
and of the symphysis. 4 

With this single exception, I am not able to find a recorded example 
of a fracture of this process. 

At least nine cases have been reported of fracture of the condyles, in 
all of which the separation occurred through the neck, viz., three by 
Ribes. two by Desault. one by Berard, one by Houzelot, one by Bichat, 
one by Packard, of Philadelphia, and two by Watson, of New York ; 
the fracture always occurring through the neck and just below the in- 
sertion of the external pterygoid muscle. 

According to Malgaigne, the analysis of these cases, excepting those 
mentioned by Packard and Watson, shows two classes of examples ; the 
one occasioned by falls or blows upon the chin, and producing ;i simple 
fracture of the neck of the condyle: the other occasioned by injuries 
inflicted upon the side of the face, and producing a fracture of the neck- 
on the side corresponding to that upon which the injuries are received, 
and at the same time a fracture of the body upon the opposite -id-'. 
These two varieties seem to be about equally common. 

1 Trans. Amer. Med. A-- R iport on "Deformities after Fractures," vol. viii. 

17. 

2 Malnaiirne. op. oit. p. 337, from Ledran, Observ. Chirurg., torn. i. obs. vii. 

3 Smith. New York. Journ. of Med., Jan. 1867. Bellevue Bosp. Report*?. 

4 Malgaigne, op. eit . p. J 11 ". 



136 FRACTURES OF THE LOWER JAW. 

In the case mentioned by Houzelot, and already cited, there existed 
at the same time a fracture of both condyles, of both coronoid processes, 
and at the symphysis. The man also whom Watson saw in the New 
York Hospital had fallen from the yard-arm of a vessel, breaking his 
thigh and arm bones and both condyles of the lower jaw. " His face 
was somewhat deformed by the retraction of the chin ; the mouth could 
not be opened so as to protrude the tongue to any great extent beyond 
the teeth, and the teeth of the upper and lower jaws could not be brought 
into contact. In attempting to move the jaw, the patient experienced 
pain and crepitation just in front of the ears ; the crepitation could 
easily be felt by placing the fingers over the fractured condyles. Nothing 
was done for the fractures of the jaw. In a few weeks the rubbing of the 
broken surfaces and attendant soreness ceased to trouble him ; but the 
shape of the jaw, and difficulty of opening the mouth to any great extent, 
still remained unaltered." 1 

Etiology. — The causes, in such cases as I have myself investigated, 
seem generally to have been direct blows, in most instances inflicted by 
a club, or by the kick of a horse ; in two examples the blow was inflicted 
by the fist. I have also seen a fracture immediately in front of the 
right cuspid, in a lad eight years of age, produced by being pressed be- 
tween two wagons, the pressure being made upon the two angles of the 
jaw. A case came under my notice at Bellevue, in. 1879, in which a 
double fracture was produced in a young woman by the grasp of her 
husband's hand. In ten of eleven cases mentioned by Stephen Smith, 
the causes were direct blows. Examples of fracture of the inferior 
maxilla from indirect blows have, however, been mentioned by other sur- 
geons, the angles of the bone being pressed together by the passage of 
a wheel, and the fracture taking place usually toward the symphysis. 

We have already alluded to the observation of Malgaigne, that frac- 
tures of the condyles belong to two classes : the one being occasioned by 
falls upon the chin, and the other by blows upon the side of the face ; 
the former acting as a counter-force, and the latter as a direct. 

The coronoid process can only be broken by a direct blow. 

Symptoms. — Fractures of the body of the bone are characterized by 
the usual signs of fracture elsewhere, namely, displacement, mobility, 
crepitus, and pain. 

The displacement is generally present ; but its direction and amount 
vary according to the situation and course of the fracture, and also ac- 
cording to the violence and direction of the force producing the frac- 
ture. I have seen several cases unaccompanied with displacement, and 
one of these I think ought to be regarded as an example of a partial 
fracture. 

A lad, yet. 9, was kicked by a horse on the 22d of June, 1858, the 
blow being received on the right side of the jaw. I saw him very soon 
after the accident, but could not detect any fracture, only the body of 
the jaw seemed to be bent in. On the third day, however, while en- 
deavoring to straighten the jaw by violent pressure from within out- 
wards, I detected a feeble crepitus, which on more careful examination 

1 New York Journ. of Mod., Oct. 1840. Hospital Reports. 



FRACTURES OF THE LOWER JAW. 137 

proved to be opposite the second incisor of the right side. I was also 
able to detect a slight motion at the same point. It was found impos- 
sible to rectify the bending, and no farther efforts were made. After the 
lapse of nearly a year, the natural curve was found to be partially, but 
not completely, restored. 

Ledran and other surgeons have also seen examples where neither the 
periosteum nor mucous membrane was torn. 

Generally j in fractures of the body, the anterior fragment is depressed : 
and Malgaigne affirms that where an overlapping occurs, the anterior 
fragment lies, generally, within the posterior; a fact which lie explains 
by the direction which the line of fracture usually takes, namely, from 
without, inwards and backwards, as we have already mentioned. In 
one instance reported by me to the American Medical Association, 
where the jaw was broken at the symphysis and also on both sides 
through the body, the central fragments were found, after about four 
weeks, lifted two lines above the lateral fragments, and also slightly 
earned backwards. 1 I have twice also met with examples in which the 
posterior fragments were inclined to fall inwards toward the mouth, a 
circumstance which seemed to indicate that the course of the obliquity 
was in a direction opposite to that which Malgaigne has observed to be 
most frequent. In each of these examples the jaw was broken upon both 
sides, by blows inflicted with a club, and the fractures were situated well 
back. 2 It is possible, however, that the position of the fragments was 
due rather to the direction and force of the impression than to the direc- 
tion of the line of fracture. 

As to the action of the muscles in the production of displacement, 
Boyer, S. Cooper, Erichsen, and Malgaigne have observed that their 
action upon the anterior fragment is greater in proportion as the fracture 
is nearer the symphysis, and less in proportion as it approaches the 
angle. So that in the former case the attempt to close the mouth is 
sometimes attended with a depression of the anterior fragment, causing a 
separation of the fragments at their alveolar margins ; while in the 
latter case the attempt to close the mouth forcibly is occasionally attended 
with separation of the fragments along the line of the base. 

While I am not prepared to deny the accuracy of these observations. 
it is proper to notice that Liston found the greatest displacement when 
the fracture was opposite the first molar; and I must confess that the fact, 
as stated by Boyer and others, does not seem to admit of a satisfactory 
explanation, since the number, and consequently the power, of the muscles 
which act upon the anterior fragment from below is greater in proportion 
as the line of fracture is further back. These muscles, namely, the 
digastricus, the genio-hyoglossus, and the mylo-hyoideuB, with several 
other muscles which act less directly, all tend to depress the anterior 
fragment, and in some slight degree to carry it backwards: ;i direction 
which, indeed, it usually takes, and which it would probably always t;ik<- 
if left alone to the action of the muscles, If the fracture has occurred 
through tie- angle, or at any point within the attachments of the mass 

1 Trans. Amer. M vol, viii. p. 380, 1855, C 

ad 10. 



138 FRACTURES OF THE LOWER JAW. 

muscle, the action of those fibres of this muscle which remain connected 
with the anterior fragment will sufficiently explain the fact that it is not 
now so easily depressed below the level of the posterior fragment; whilst 
the separation of the fragments along the line of the base, when an 
attempt is made to close the jaw forcibly, is probably due to the loosening 
and partial dislodgement of some of the molars, which, being pressed up- 
wards, act as a pivot upon which the fragments are made to bend. 

Boyer affirms, also, that "the fractured portions are never deranged so 
that one overrides the other in the direction of their length; for the 
action of none of the muscles of the lower jaw is parallel to the axis of 
that bone ; besides, its extremities are retained in the glenoidal cavities of 
the temporal bones." But this theory is too exclusive, since the frag- 
ments may have become displaced in any direction independently of the 
muscular action. Moreover, the action of the muscles attached to the 
anterior fragment, although not parallel to the axis of the bone, does 
somewhat favor a displacement in this direction; and the action of the 
pterygoid muscles upon the posterior fragment still further favors this 
form of displacement. 

An overlapping of the fragments in the direction of the axis is, in 
simple fractures, no doubt, exceptional, and in such examples as I have 
seen it was very trivial. It occurred in case "three" of my "Report," 
the fracture being near the mental foramen; in case "two," the fracture 
being just anterior to the last molar; and also in case "six," where the 
bone had been broken through the centre of the body on both sides and 
through the symphysis; but in neither case did the overlapping exceed 
two or three lines, and it was always easily overcome. 

The mobility of the fragments is not so striking in these accidents as 
in fractures of the long bones, yet it is generally sufficiently marked, and 
especially where the bone is broken upon both sides at the same time. 
If only one side is broken, both motion and crepitus will be most easily 
detected by lateral pressure upon the posterior fragment, which, being the 
smallest and the least supported by antagonizing muscles, will be found to 
be the most movable. If the fracture is upon both sides, mobility and 
crepitus will be most readily developed by seizing upon the anterior frag- 
ment and moving it gently up and down, while the finger rests upon the 
alveolus within the mouth. 

Sometimes a slight swelling or tenderness at some point of the dental 
arcade, or the loosening or complete dislodgement of a tooth, will indicate 
the point of fracture. 

Pain, especially when the fragments are moved, is here more constant 
than in most other fractures, owing perhaps, in part, to the superficial 
position of the bone, which renders the soft parts lying over it more liable 
to injury from the causes of fracture; but also, in part, to the lesions 
which the inferior dental nerve may have suffered. It is, indeed, a 
matter of surprise that injury to this nerve does not often er seriously 
complicate these accidents, coursing, as it does, through so large a por- 
tion of the angle and body of the bone. One might naturally suppose 
that its complete disruption would often occasion paralysis of those por- 
tions of the face to which it is finally distributed, and that its partial 
lesions and contusions would create, in many cases, the most acute and 



FRACTURES OF THE LOWER JAW. 139 

constant suffering. It is rare, however, that we have present an amount 
of pain which might not he attributed to a severe shock, or a slight strain 
upon its fihres. I have myself never seen any extraordinary suffering 
distinctly attributable to an injury of the dental nerve after fracture: nor 
any degree of facial paralysis, except in the case to he hereafter described. 
Rossi relates a case in which convulsions followed this accident, and in 
which, as a final remedy, he proposed to expose and bisect the nerve: and 
Flajani saw a patient, whose jaw had been broken, die in convulsions on 
the tenth day. the muscular contractions having commenced as early as 
the fourth day after the accident. The autopsy disclosed a rupture of the 
dental nerve, but no injury to the brain. 

Boyer explained the infrequency of severe injury to the dental nerve by 
the supposition that the "greater part of these fractures take place 
between the symphysis and the foramen by which this nerve comes out." 
An opinion which may be correct, but needs confirmation. I have seen 
the body or angle broken at points posterior to the mental foramen, and 
where the nerve lies within its bony canal, at least thirteen times, and in 
front of the mental foramen nine times : at other times the point of frac- 
ture has not been noted with such accuracy as to enable me to say 
whether it was in front or behind the foramen. 

I suspect that a better explanation may be found in the fact that the 
fragments seldom overlap to any appreciable extent, and that even the 
displacement in the direction of the diameters of the bone is generally 
inconsiderable; or, if it does exist, the fragments are easily and promptly 
replaced. 

If the displacement is sufficient to occasion a complete disruption of the 
nerve, some degree of temporary paralysis in the portions of the face 
supplied by it must be inevitable: and. perhaps this occurs oftener than 
it has been noticed, since, during the confinement of the jaw by dressings, 
it is not likely to be observed, and after the lapse of a few weeks it will 
probably cease altogether. 

Boyer remarks that when it is torn, "the square and triangular muscles 
of the chin are paralyzed. The skin of that part and the internal 
membrane of the under lip preserve their sensibility, which it appears 
they owe to some threads of the portio dura of the seventh pair : but 
the paralysis of these muscles does not prove of itself that the jaw is 
fractured." Boyer has. however, noticed this result but once, and then 
in a case where the bone was broken upon both side- and the soft parts 
greatly contused. The triangular and square muscles were paralyzed, 
in consequence of which there was n slight contortion of the mouth. 
A. Berard has also mentioned a case of vertical fracture occurring 
between the second and third molars, without displacement, which was 
accompanied with complete insensibility of the lip on the same side 
throughout the space comprised between the commissure and the median 
line, and between the free border of the lip and tie- chin. The paralysis 
peared after a few day-. 1 

At my request, Dr Frederick 8. Dennis, junior assistant at Bell 
II 3] ital 1 v 74i. furnished me with the following account of ;i case lately 

1 Malgaigne, from Gazette dee Hdpitaux. 10 Aotit, 1841. 



140 FRACTURES OF THE LOWER JAW. 

presented in one of my wards. I shall take the liberty of condensing 
somewhat the very full and interesting history which he has furnished 
me; remarking, however, that the observations are all the result of his 
own careful investigation. 

Kate Campbell, set. 30, was admitted December 11, 1874, suffering 
fnnn an attack of acute tonsillitis. I subsequently opened an abscess in 
the tonsil, and she was soon discharged cured. While taking notes of 
her case. Dr. Dennis learned the following facts. More than a year 
before she had received a fracture of the lower jaw, right side, and a 
distinct callus remained near the angle of the jaw to indicate the point 
at which the fracture had occurred. Since that time there has existed 
complete insensibility of that portion of the face which is supplied by 
the inferior dental nerve and its branches. Careful experiments were 
made with different substances, and with sharp instruments, all of which 
indicated "that the nerve was destroyed in the immediate vicinity of the 
dental foramen. The gustatory nerve, as well as the chorda tympani 
from the facial, maintained their full physiological functions, both in 
reference to general sensation, and the special sense of taste. The mylo- 
hyoid branch of the inferior dental, which is given off just before the 
nerve enters the dental foramen, and which is motor in action, was not 
in the least impaired." Over the entire region supplied by the inferior 
dental nerve there was complete anaesthesia. Pins, thrust through the 
integument into the buccal cavity, caused no sensation. "The gums as 
well as the teeth, on the side corresponding to the fracture, were in a 
state of analgesia." 

The case above described furnishes an example of permanent paralysis 
of the inferior dental nerve, from fracture ; and upon this point the 
following comments made by Dr. Dennis, are of special interest : 

"Haemorrhage into the dental canal, or a slight laceration of the 
inferior dental nerve, with little displacement of the fragments, may 
cause a paralysis, which, in the former case after absorption, and in the 
latter case after repair of nerve-tissues, eventually terminates in complete 
recovery ; but in the case under consideration there is no hope of the 
restoration of the function of the nerve, as too long a time has intervened, 
according to the views of the most sanguine neurologists. 

"Malgaigne has never seen a case of total destruction of the inferior 
dental nerve, in which permanent paralysis followed, from a fracture of 
the lower jaw. He believes the severe pain, which frequently occurs, to 
be due to cerebritis rather than to injury of this particular nerve. He 
further states, in his work on " Fractures," that the cases in which the 
nerve is injured, even in a slight degree, are very rare. 

"Petit, Rossi, Flajani, Foucher, Robert, and many other writers on 
this subject, give examples where the paralysis was of short duration; 
and they say that they have never seen a case where the paralysis re- 
mained permanent. The only cases that can be found, in the researches 
that have been made, where the paralysis was permanent, is one reported 
by Desirabode in the Journ. des Connaissances, 1857, No. 20, p. 538 ; 
and in this case the symptoms of injury of the inferior dental nerve are 
identical with those found in the case of Kate Campbell. The paralysis, 
in the case which Desirabode reports, was caused by a crude dental 



FKACTURES OF THE LOWER JAW. 141 

instrument, which tore the alveolar processes of seven teeth, and exposed 
the dental canal." 

To these signs now enumerated, we may add as occasional complications, 
rather than as diagnostic symptoms, salivation, swelling of the submax- 
illary and sublingual glands, abscesses, necrosis, etc. If the blow has 
been vertical upon the chin, and the direction of its force has been toward 
the articulations, the bony structure of the ear. and even the brain, may 
have suffered serious lesions, which may be indicated by a deafness or a 
roaring in the ears, by bleeding from the external meatus, and by fatal 
coma. Tessier saw a man who had received the kick of a horse exactly 
upon the centre of the chin, breaking the bone on both sides, and who. 
in consequence, bled freely from his ears : l and Alix relates the case of a 
young man who, foiling from a height and striking upon his chin, had 
broken his jaw. Insensibility immediately followed ; convulsions also 
ensued upon the fourth day. and he died upon the sixth. 2 

If the fracture is at the symphysis, it is generally vertical, and either 
fragment may be found slightly displaced upwards or downwards. In 
one of the examples seen by myself, the left fragment fell three lines 
below the right, and in another the right side had fallen about one line. 
In a case mentioned by Syme there was scarcely any displacement. 3 
Liston remarks that it is usually slight. Erichsen and B. Cooper have 
observed the same. 

The signs which indicate a fracture through the angle have already 
been sufficiently considered when speaking of fractures of the body ; from 
which it only differs in the less degree of displacement, and in the fact 
that the posterior fragments are a little more prone to fall inwards 
toward the mouth. I have noticed, also, that, owing probably to the 
loosening and partial dislodgement of the last molar, it is sometimes 
difficult to close the mouth, the same as in the fractures a little farther 
forwards. 

In each of the two examples of fracture of the ascending ramus which 
I have seen, the bone being broken also through its body, the fracture of 
the ramus was recognized by both crepitus and mobility. 

As to the signs which indicate a fracture of the coronoid process, I am 
only aide to infer them from its anatomical relations. There must be 
Borne embarrassment in the motions of the jaw, occasioned by the detach- 
ment of a portion of the fibres of the temporal muscle; and it is probable 
that an examination by the finger within the mouth would readily detect 
mobility and displacement. 

A fracture through the neck of the condyle is characterized by pain 
;it the seat of fracture, especially recognized when an attempt is made to 
open or shut the mouth, by embarrassment in the motions of the jaw. by 
crepitus, which may usually be felt or heard by the patient himself, by 
mobility and displacement. 

The upper fragment, if disengaged from the lower, is drawn forwards, 
upwards, and inwards, by the action of the pterygoideus externus; and 
it is felt not to accompany the movements of the lower fragment. 

1 Malg ] I, from Journ. de M6d , 1789, torn Ixxix p 246J 

. p. 386, from Alix. Observata Chir , fascia I, obs. 10. 

Ainer. Joum. Med. 8ci., vol. xviii. ],. 248. 



142 FRACTURES OF THE LOWER JAW. 

The lower fragment is at the same time drawn upwards, in consequence 
oi' which the lower part of the face is distorted; a circumstance first 
noticed by Kibes, and which supplies an important diagnostic mark 
between a fracture of one condyle and a dislocation. In dislocation the 
chin is commonly thrown to one side, but it is to the side opposite that 
on which the dislocation has occurred, while in fracture the chin is drawn 
to the same side. 

Prognosis. — Physick, of Philadelphia, saw a case of non-union of the 
body of this bone which had existed nine months. 1 Dupuytren mentions 
"a case which had existed three years. 2 Stephen Smith, of New York, 
reports a case of fracture of both the body and the ramus, in a man 
forty-five years old. The severity of the injury, with the supervention 
of delirium tremens, prevented the application of dressings until the 
thirteenth day. On the twentieth day about a pint of blood was lost by 
haemorrhage from the seat of fracture. He remained in the hospital one 
hundred and thirty-seven days, and was finally discharged, the fragments 
not having yet united. 3 I have seen four examples of fibrous union. In 
Dr. Muhlenberg's tables sixteen examples are enumerated out of a total 
of six hundred and fifty-six cases of non-union and delayed union. 4 In 
no instance of a simple fracture which has come under my personal care 
from the first, has the bone refused finally to unite, although I have seen 
the union delayed six, seven, ten, and even eleven weeks or more. 5 In 
three of these cases the fractures were either compound or comminuted ; 
but in one case the fracture was simple, the delay in the union being due 
to a feeble condition of the system, and in part, perhaps, to neglect of 
proper treatment. Since the commencement of the late war I have met 
with several examples of non-union, and of fibrous union, after gunshot 
fractures ; but, so far as I can remember, in all of these cases necrosis 
existed, or some portions of the bone had been carried away. 

The infrequency of non-union after this fracture is a fact worthy of 
especial attention, because of the extreme difficulty, if not actual impos- 
sibility, in many cases, of wholly preventing motion between the frag- 
ments, by any mode of dressing yet devised. Any one who has observed 
attentively, must have seen, not only that his dressings are more often 
found disturbed and loosened than in the case of almost any other fracture, 
unless it be the clavicle, and thus the fragments have been through all 
the treatment subjected to frequent changes of position ; but, also, that 
even while the dressings remain snugly in place, the patient seldom is 
able to perform the necessary acts of deglutition, or to speak, even, 
without inflicting some slight motion upon the fragments. 

Indeed, the rapidity as well as certainty with which this bone unites, 
has, I think, been observed by other surgeons, and I have myself noticed 
one instance, in an adult person, in which the bone was immovable at the 
seat of fracture on the seventeenth day, and perhaps earlier. In other 
instances, the union has been speedily effected after the removal of all 
dressings. 

1 Phila. Med. and Surg. Journ., vol. v. 2 Legons Orales. 

8 Smith, Xew York Journ. of Med. and Surg., Jan. 1857. 
' Agnew's Surg., op. cit., vol. i. p. 804. 
5 My Report on Deformities after Fractures, Cases 2, 14, 15, 18. 



FRACTURES OF THE LOWER JAW. 143 

The amount of deformity resulting, also, from these fractures is usually 
very trilling, whatever treatment has been adopted. Only nine of the 
united fractures, seen and recorded by me. are imperfect, and in none of 
these is the imperfection such as to be noticed in a casual examination of 
the face. The deformity which is usually found, is a slight irregularity 
of the teeth, produced, in most cases, by a falling of the anterior fragment, 
but in one case by a slight elevation of the anterior fragment. But even 
this does not always interfere with mastication, and would often pass 
unnoticed by the patient himself. It is probable, too, that time, and the 
constant use of the lower jaw in mastication, will gradually effect a 
marked improvement in the ability to bring the opposing teeth into con- 
tact. I think I have observed this in several instances. 

In a letter dated Sept. 30. 1876, Dr. John H. Packard, of Philadel- 
phia, informs me that in a case of fracture of the lower jaw, occurring 
near the left anterior mental foramen, the right fragment was so forcibly 
displaced downwards, by the action of the muscles, that he was obliged 
to sever their attachments at the symphysis, in order to retain the frag- 
ments in place. 

Chelius remarks that in " double or oblique fractures it is very difficult 
to keep the broken ends in their proper place; deformity and displace- 
ment of the natural position of the teeth commonly remain." 

In the second example of fracture through the symphysis mentioned 
by me. the left fragment remained slightly elevated, and the patient could 
not close his teeth perfectly, yet he could close them sufficiently for the 
purposes of mastication. It is probable, however, that ordinarily no 
difficulty will be experienced in accomplishing a perfect cure when the 
separation has taken place only at the symphysis. 

In fractures of the condyles, more care is requisite to retain the frag- 
ments in apposition, and sometimes it may be found to be impossible. 
Richerand mentions the case of a man, who, having been three months 
in the Hopital de la Charite," for a double fracture of the lower jaw, 
one fracture being near the middle, and the other near the right condyle, 
left before the cure was complete. Seven or eight months after, he called 
upon Boyer. who extracted, from a fistula in the meatus auditorius ex- 
ternus. a bony mass which had evidently the form of the condyle. 1 Bichat 
mentions a similar case as having come under the observation of Desault: 2 
possibly it was the same which Boyer saw. Ribes says that a Parisian 
surgeon treated a double fracture of the jaw in a gentleman, one fracture 
being through the body and the other through the neck of the condyle: 
and, in spite of the most assiduous and skilful attention, the patient 
recovered with a lateral distortion of the jaw, occasioned by the displace- 
ment of the fragments. 3 Ribes himself had to treat an accident of a 
similar character, and. notwithstanding all his care, the result was the 
same as in the other example just cited. 4 Fountain, of Iowa, was much 
more fortunate, having made a complete and perfect cure.' 

The proximity of this fracture to the articulating surface may occasion 

1 Boyer, Lectures on Dis. of Bones, \>. 63, Phila. ed., 

2 Default. Treatise on Fractures and Luxations, Phila. ed., 1806, p. 8. 
s Malg . . cit., p. 402. 4 Ebid., p. K)2. 
5 Fountain. New York Journ. Med., Jan. 1860. 



144 FRACTURES OF THE LOWER JAW. 

contraction of the ligaments about the joint: and a degree of embarrass- 
ment to the motions of the jaw has followed in the experience of Desault 
and others, even when the cure has been most complete; but this has 
usually remained only for a short period. 

Sanson asserts that when the coronoid process is broken, the fracture 
never unites: but that mastication is performed very well, the masseter 
and pterygoid muscles then fulfilling the office of the temporal. 1 

Treatment, — The few attempts which I have made to restore a com- 
pletely dislocated tooth to its socket, or to retain it in place when very 
much loosened, have generally resulted in its removal at some later day, 
and especially where the fracture has been near the angle and a molar 
lias been disturbed. I believe it would be better practice always to 
remove the molars under these circumstances, unless they remain attached 
to the alveoli, and cannot be removed without bringing them away also ; 
and this, whether the loosened teeth are situated in the line of fracture 
or not. It is seldom that they can be made again to occupy their sockets 
perfectly, and where the teeth are in the line of the fracture, the attempt 
to restore them to place will sometimes prevent the proper adjustment of 
the fragments. In cases, also, in which the teeth farther forwards are 
completely dislodged at the seat of fracture, it is scarcely worth while to 
replace them. 

As to those teeth whose loosened condition is due only to a splitting of 
the alveoli in a longitudinal direction, the same rule will not always 
apply. Sometimes, after a careful readjustment, the fragments will 
reunite, and the teeth remain firm. 

If the bone is chipped off upon the outside, through or near the line 
of the sockets, the teeth may be not always much disturbed, and the loss 
of the fragments may be of less consequence, nor have I generally suc- 
ceeded in saving them ; yet, if they remain adherent to the soft parts, it 
is proper to make the attempt. 

The expedients to which surgeons have resorted for the purpose of 
retaining in place the fragments, when the bone is broken through its 
body, may be arranged under the names of ligatures, splints, bandages, 
and slings. 

The ligature has been applied both to the teeth and to the bone itself. 
Thus, in an oblique fracture near the angle, where the fragments could 
not otherwise be prevented from falling inwards, Baudens passed a strong 
ligature, formed of thread, around the fragments and in immediate con- 
tact with them, tying the ligature over the teeth within the mouth. Xo 
accident followed, and on the twenty-third day, when he removed the 
ligature, the bone had united firmly and smoothly. 2 

Picharel and Berenger-Feraud have successfully practised the same 
method in certain very oblique fractures of this bone, where it seemed im- 
practicable to employ other means. 3 

In most cases, however, the ligature, when applied directly to the bone, 
lias been employed as a suture, in the form of metallic wire. Thus, in the 

S. Cooper's First Lines, Amer. ed., 1844. vol. ii. p. 311. 
- Malgaigne, op. eit., p. 398. 

:) JBeren^er-Feraud, Traite de immobilization direct. Paris, 1870. (Poinsot.) 



FRACTUKES OF THE LOWER JAW. 1±5 

case of the fracture of the inferior maxilla, reported by Dr. Buck to the 
New York Pathological Society, and already referred to. the bone "was 
broken between the two incisor teeth of the left side: the part of the bone 
on the left of the fracture was driven in. and interlocked behind the end 
of the right portion, so as to be separated by a finger's breadth. Finding- 
it impossible otherwise to reduce the fracture. Dr. Buck dissected oft* 
the under lip. so as to expose the fracture. He found that the right 
anterior portion of the fractured bone terminated in an angular projection 
as far as on a line below the left angle of the mouth. The lip was then 
divided to the chin, and the soft parts holding the fragments together 
incised. A chisel was then insinuated behind the projecting angle of 
the bone, while it was being excised by the metacarpal saw. When the 
bone was restored to its natural position, it was found so apt to become 
displaced that holes were drilled at the lower angle of the fracture, and 
adjustment maintained by wiring them together, the wire passing out 
through the lower angle of the wound. Sutures and adhesive straps, 
with a bandage, were employed to maintain the adjustment of the parts. 
So tar the patient has done well, being supported by liquid nourishment 
introduced through a tube passed through the space left by one of the 
incisors, which, on account of its looseness, was removed." 1 Dr. R. A. 
Kinloch. of Charleston. S. C. has reported a similar case, in which he 
employed successfully the wire. 2 

In May. 1858. while trephining at the angle of the jaw for the pur- 
pose of cutting out a portion of the dental nerve in a patient suffering 
from neuralgia. I accidentally broke the jaw in two at the point at which 
the trephine was applied. I immediately bored a hole in the opposite 
extremities of the two fragments, and fastened them together with a 
silver wire, by which I was able to maintain complete apposition, and in 
three weeks the union was accomplished, the wire separating and falling 
out of itself. Xo splints were ever used. 3 

James O'Neill, set. 38, received a fracture of the inferior maxilla on 
the right side, between the second bicuspid and second molar. He came 
under my notice May oth. nearly three months after the accident oc- 
curred. The fragments were united with a fibrous band, and with a 
good deal of displacement. I sent him to a dental infirmary, but the 
efforts to replace and retain the fragments, made by the gentleman in 
charge, were unsuccessful, and on the 20th of June following I operated, 
by making an external incision to the point of fracture, exposing the 
bone thoroughly, ami. having freshened the broken surfaces, the frag- 
ments were perforated and secured in apposition with a silver wire. 
August 12th the ligature was removed, a bony union being effected with 
but little displacement. Other Burgeons have reported similar successful 
examples. 4 

My experience has been that the perforations must be made perpen- 
dicularly, not obliquely, through the fragments, and some distance from 
their margins; and that to withdraw the wire or to return it from within 

1 New York Journ. of Med., etc., March, 1847, p. 21 1. 

2 Kinloch, Am. Journ. Med. Bci., July, 1869, p. '.7. 

3 Buffalo Med. Journ.. vol. xiv. p. 148. 

4 Beranger-Feraud. (Poinfi 

10 



14b' FRACTURES OF THE LOWER JAW. 

outwards, an instrument with a straight shaft, rather smaller than the 
perforation, and furnished with an abruptly curved, blunt extremity, is 
required. The wire should be large, strong, and flexible, and the perfo- 
ration should be twice as large as the wire. The instrument and method 
devised by Mr. Thomas, Liverpool, in 1863, and reprinted in Kingsley's 
work on " Oral Deformities," is not satisfactory. 

Ordinarily the ligature has been employed only as a means of reten- 
tion, by fastening it upon the teeth, either upon those which are situated 
on the opposite sides of the fracture, or upon others a little more remote, 
or upon the corresponding teeth of the upper jaw, or upon the teeth on 
the opposite sides of the same jaw. 

In most cases the ligature, composed of either fine gold, platinum, or 
silver wire, or firm silk or linen threads — (Celsus advised the use of 
horsehair) — has been applied to the two teeth on the opposite sides of 
the fracture, or, if these have not been sufficiently firm, to the next teeth. 
This practice, recommended first by Hippocrates, has received the occa- 
sional sanction of Ryff, Walner, Chelius, Lizars, Erichsen, Miller, 
B. Cooper, Skey, and others, but by Boyer, Gibson, and Malgaigne it 
has been disapproved. 

Dr. S. G. Ellis, of New York, as we have already seen, has treated 
a fracture, occurring through the symphysis, in an adult, by placing the 
mainspring of a watch within the dental arcade, and securing it in place 
with silver wire. The mouth was kept closed by bandages carried under 
the chin. The fragments united with only a slight vertical displacement. 1 

Dr. George Hayward, of Boston, surgeon to the Massachusetts Gen- 
eral Hospital, says : "When the bone is not comminuted and there are 
teeth on each side of the fracture, the ends of the bone can be kept in 
exact apposition by passing a silver wire or strong thread around these 
teeth and tying it tightly. In several cases of fracture of the jaw, in 
which the bone was broken in one place only, I have, in the course of 
the last few years, adopted this practice with entire success, and without 
the aid of any other means. It will be found very useful, also, as an 
auxiliary, in more severe cases, in which it may be required to use splints 
and bandages, or to insert a piece of cork between the jaws, as recom- 
mended by Delpech. It requires some mechanical dexterity to apply 
the thread neatly ; but in large cities we can avail ourselves of the skill 
of dentists for this purpose." 2 I have myself in two or three instances 
used a linen thread with excellent results. 

Guilio Saliceto advises to secure with a silk thread, at the same mo- 
ment, the teeth belonging to the two fragments, and the corresponding 
teeth of the upper jaw ; 3 whilst the dentist Lemaire, being applied to by 
Dupuytren to secure in place the ununited fragments of a broken jaw, 
fastened the two left canine teeth to each other by a wire of platinum, as 
had been already suggested by Guilio Saliceto ; to those he added two 
other modes of ligature which were altogether original. One wire, 
fastened to the last molar upon one side, traversed the mouth and was 

1 Trans. Amer. Med. Assoc. My Report on " Defor.," etc., vol. viii. p. 383, Case 14. 
» Boston Bied. and Suig. Journ., vol. xix. p. 133, 1838. 
Malgaigne, op. cit, p^ 392. 



FRACTURES OF THE LOWER JAW. 147 

secured to one of the bicuspids upon the opposite side; the other was 
stretched from the first inferior bicuspid on the right to the first superior 
bicuspid on the left. A cure was accomplished at the end of two months, 
but one of the wires had nearly bisected the tongue ; and as it had 
gradually become imbedded, the flesh had closed over it until it rested 
like a seton through the middle of the tongue. 1 

None of these various methods, however, will in general be found to 
possess much value : for besides that they are all of them, in a large 
majority of cases, wholly unnecessary, and in other cases, owing to the 
absence of the teeth, or to their loosened or decayed condition, or to 
the closeness with which they are set against each other, absolutely im- 
practicable, it must be seen, also, that they will generally prove feeble and 
inefficient. The wires act only upon the upper extremity of the line of 
fracture, leaving its lower portion liable to be disturbed by trivial causes : 
they tend gradually to loosen even the firm teeth which they embrace, 
and not unfrequently, after having been made fast with much labor, they 
soon become disarranged or break. They require, therefore, almost 
always the additional protection afforded by bandages, interdental splints, 
etc. Alone they are usually insufficient, and if properly constructed 
bandages, slings, interdental splints, etc., are employed, they are not 
needed. Sometimes, moreover, they are actually mischievous, as when 
they loosen a sound tooth or press upon and inflame the gums. A. Berard 
passed a silver wire twice around the necks of two adjoining teeth on the 
opposite sides of a fracture. It retained the fragments perfectly in 
apposition during several days ; but soon the gums swelled and became 
painful ; the teeth loosened, and it was found necessary to remove the 
wire. Chassaignac sought to avoid these evils by placing the wire upon 
the middle of the crown, free from the gums, and by including four 
teeth instead of two. A waxed linen thread was made fast in this man- 
lier, in a case of simple fracture, on the seventh day. On the following 
morning the thread was found broken. He applied then a silk ligature 
in the same manner. On about the third day this also was disarranged ; 
the ligatures were now discontinued until the eighteenth day, when he 
renewed the experiment with a piece of gold wire. Fourteen days after 
this the ligature remained firm, but the gums were red and bleeding. 
The patient not having again returned to Chassaignac, the result is not 
known. 2 

A- to the method suggested by Guilio Saliceto, it presents no advan- 
to compensate for its inconveniences; while that actually practised 
by the dentist Lemaire, successful indeed, threatened to substitute a lo- 
ot" the tongue for an ununited fracture of the jaw. 

Splint- have been employed in various ways. First, simply interdental 
splints, laid along the crown- of the teeth, and only sufficiently grooved to 
be easily retained in place; second, clasps, which are applied over the 
crown- and -ides of the teeth, operating chiefly by their lateral pressure, 
or made fast by screws; third, splints applied to the outer and inferior 
margin of the jaw; fourth, interdental splints combined with outside 
splint-. 

1 Journ. Univer. . torn. ax. p. 77. 

2 Lend. Mod. and PL 322, p. 101. 



148 FRACTURES OF THE LOWER JAW. 

Interdental splints have been recommended by many surgeons from an 
early day, and they continue to be employed occasionally up to this moment. 

Boy or advises the use of cork splints, placed one on each side between 
the upper and lower jaws, in a few exceptional cases. Miller recommends 
the same in all cases, the "two edges of cork sloping gently backwards, 
with their upper and under surfaces grooved for the reception of the 
upper and lower teeth." Fergusson also has usually adopted the same 
practice. Muys and Bertrandi employed ivory wedges. 1 

On the other hand, interdental splints are rejected entirely by Syme, 
Chelius, Skey, Erichsen, and Gibson. 

The objections which have been stated to their use are: that they are 
unsteady and become easily loosened and disarranged ; that they occa- 
sionally press painfully upon the inside of the cheeks ; that they accu- 
mulate about themselves an offensive sordes; and finally that they are 
unnecessary, since experience has proven, says Gibson, that "there is 
always sufficient space between the teeth to enable the patient to imbibe 
broth or any other thin fluid placed betw T een the teeth." 

It is not strictly true, however, that in all cases there will be found 
sufficient space between the teeth, when the mouth is closed, for the im- 
bibition of nutrient fluids. I have myself seen exceptions ; and in such 
a case the patient, if the mouth Avere closed in the usual way, would have 
to be fed through a tube conveyed along the nostrils into the stomach, as 
suggested by both Samuel and Bransby Cooper in certain bad compound 
fractures, or through an opening made by the extraction of one of the 
front teeth; neither of which methods ought to be preferred to the inter- 
dental splints ; but then the separation of the front teeth for the purpose 
of receiving food, is by no means the only object to be gained by their 
use, nor indeed the principal object. Their great purpose is to act as 
splints whenever the absence of teeth, either in the upper or low T er jaw, 
renders the two corresponding arcades unequal and irregular, and prevents 
our making use of the upper as a kind of internal splint for the lower 

It is with a view to the accomplishment of this important end that 
they are often valuable, and ought sometimes to be considered as indis- 
pensable. I believe also, that many of the inconveniences which have 
been found to attend the use of cork or wood, are obviated by the sub- 
stitution of gutta percha in the manner which I recommended to the 
profession in 1849, 2 and also again in my report to the American Medical 
Association, made in the year 1855. 

The mode of preparing gutta percha, and of adapting it between the 
teeth, is as follows : Dip a couple of pieces of the gum, of a proper size, 
into hot water ; and when they are softened, mould them into wedge-shaped 
blocks, and carry them to their appropriate places between the back teeth 
on each side of the mouth ; taking care, of course, that on the fractured 
side the splint extends sufficiently far forwards to traverse thoroughly the 
line of fracture. Now press up each horizontal ramus of the jaw until 
the mouth is sufficiently closed, and the line of the inferior margin is 

1 Loud. Med.-Chir. Rev., vol. xx. p. 470. 

2 Buffalo Med. and Surg. Journ., vol. v. p. 144, Aug. 1849. 






FRACTURES OF THE LOWER JAW. 149 

straight: in this position retain the fragments a few minutes, until the 
gum has well hardened. Meantime it will be practicable, generally, to 
introduce the fingers into the mouth, and to press the gutta percha laterally 
on each side toward the teeth, and thus to make its position more secure. 
When it is hardened, remove the splints, for the purpose of determining- 
more precisely that the}?- are properly shaped and fitted. 

It is scarcely necessary to say that in carrying the long wedge-shaped 
block into the mouth, the apex of the wedge is to be introduced first. 

The superiority of this splint is now at once perceived. If properly 
made, it is smooth upon its surface, and not, therefore, so liable to irri- 
tate the mouth as wood or cork, and it is so moulded to the teeth that it 
will never become displaced. It possesses this advantage, also, that in 
case more or less of the teeth are gone in either the upper or lower jaw, 
it fills up the vacancies, and renders the support uniform and steady. 

The ••clasp," applied over the crowns and sides of teeth, is not in- 
tended to act as an interdental splint ; but by its lateral pressure it is 
expected to hold the fragments in apposition upon nearly the same prin- 
ciple with the ligature. 

Mutter, of Philadelphia, and N. R. Smith, of Baltimore, employ for 
this purpose a plate of silver, folded snugly over the tops and sides of 
two or more teeth adjacent to the fracture. 

Nicole, of Xeubourg, employed for the same purpose a couple of steel 
plates fitted accurately along the anterior and posterior dental curva- 
tures, secured in place by a steel clasp, the clasp being furnished with 
a thumb-screw, in order the more effectually to accomplish the lateral 
pressure. 

Malgaigne has extended the idea of Xicole. by substituting for the 
two steel plates a single plate composed of flexible and ductile iron, which 
is fitted accurately to all the irregularities of the posterior dental arch. 
From the two extremities of this plate, and from two other intermediate 
points, four small steel shafts arise perpendicularly, cross the crowns of 
the teeth at right angles, and then fall down again perpendicularly upon 
the anterior dental arcade. Each steel shaft being furnished with a 
thumb-screw, the iron plate can now be made to bear against the teeth 
3 to form a posterior dental splint. The teeth are also protected in 
front against the direct action of the thumb-screw by the interposition of 
a leaden plate. 

J. B. Gunning, dentist, of New York, substituted for all these mate- 
rial- vulcanized India-rubber, which he employs both as a clasp ami as 
an interdental splint; and, according to Dr. Covey, 1 the same material 
has been used with excellent results by -1. B. Bean, dentist, of Atlanta. 
Ga. The following is Dr. Bean's plan of procedure: 

An impression is taken in wax of the 'Town- of the teeth of the unin- 
jured jaw. and of each fragment separately of the broken jaw. When, 
in doing this, the ordinary "impression cup" used by dentists cannol be 
introduced, one composed of a thin metallic plate, which is covered with 
wax and stiffened by a rim of wire, may he substituted. 

••From these impressions are made casts of plaster of Paris, very 

1 Bean, Richmond Med. Journ., Feb. 1866. 




150 FRACTURES OF THE LOWER JAW. 

carefully prepared, so as to produce a smooth, hard surface, and giving 
as perfect a representation of the teeth as possible. These plaster 
models are then adjusted, properly antagonized in their normal position, 
ami placed in the 'maxillary articulator.' 

•• The fragments of the model representing the broken jaw are held in 
their proper position by wax, being secured thus one to the other, and to 

the remaining plate of the articu- 
lator." . . . The model jaws are 
now opened from three to five lines, 
and a wax model of a splint is built 
up between the molars, covering 
also the inner and outer surfaces of 
the teeth. A connecting band of 
wax is laid from one side to the 
other behind the upper front teeth, 
leaving thus an opening in front 
for the reception of food. This 

Maxillary Articulator. wax and p l aster mode J ? now com . 

1,1. Upper and lower plates. • ,i t 

2 2. Adfustabie rods. posmg one piece is then removed 

3, 3. Adjustable hinge. from the articulator, and placed in 

a dentist's "flask," and a complete 
mould of the model is again formed from plaster laid on in sections, in a 
manner which those accustomed to make plaster moulds will readily 
understand. The plaster having fairly set, the flask and mould are 
opened, the wax carefully removed, and the spaces thus left in the mould 
at once filled with the rubber rendered soft by heat. The mould is again 
closed, replaced in the flask, and by heat the rubber is thoroughly 
vulcanized. The flask is again opened, the plaster removed, and an 
interdental splint of rubber remains, which is fitted accurately to all the 
surfaces of the teeth both above and below. 

The splint is now placed in the mouth, adjusted to the teeth, and the 
lower jaw secured in position by the apparatus represented in the accom- 
panying woodcut. 

Dr. Covey says that, during the late war, Dr. Bean was placed in 
charge of a hospital at Macon, Georgia, devoted exclusively to the recep- 
tion of this class of injuries, and that over forty cases were treated, and 
with eminent success. 

My own judgment of this apparatus is, that, so far as the substitution 
of vulcanized rubber for gutta percha is concerned, it is wholly unneces- 
sary in the great majority of simple fractures of the jaw. Gutta percha 
is applied with great facility, and with equal accuracy to all the dental 
surfaces, and it speedily hardens sufficiently for all practical purposes. 

In gunshot fractures, however, and in certain other badly comminuted 
fractures, I can well understand how the surgeon may advantageously 
avail himself of vulcanized rubber, which, being somewhat harder, may 
be made to grasp the teeth attached to the several fragments more firmly; 
and, indeed, may, in a few cases, allow of the teeth being made fast to 
the splint by screws. 

It will be observed that these are the cases which Dr. Bean has had 
chiefly under treatment. 



FRACTURES OF THE LOWER JAW 



151 




Bean's apparatus for broken jaw, applied. 



An examination of the eases recorded by Dr. Covey will also show 
that the apparatus was never applied earlier than the tenth day, even 
when the patients were under the 
charge of Dr. Bean from the first, and 
that in most eases the application of 
the apparatus was delayed to a much 
later period. Indeed, it is apparent 
that there may be the same reasons 
for occasional delay in the application 
of vulcanized rubber as in the applica- 
tion of gutta percha, or any other 
mode of support and dressing. 

In reference to the head apparatus, 
or sling, as used by Dr. Bean, I 
have only a single remark to make. 
It is a modification of the apparatus 
employed for many years by myself — 
the modification consisting in the use 
of a horizontal piece of wood support- 
ing a cup which is placed under the 
chin, the purpose of which is to pre- 
vent the lateral pressure usually made by the maxillary bands. The 
necessity of avoiding lateral pressure in certain cases has long been recog- 
nized by myself and others; and it has been found to be especially im- 
portant in all comminuted and gunshot fractures. To the attainment of 
this purpose, I have employed usually a firm gutta-percha splint under 
the chin, to the projecting lateral extremities of which the maxillary 
bands have been attached; and I think it much better than Dr. Bean's 
piece of wood. In a great majority of cases, however, occurring in civil 
practice, that is to say, in most simple fractures, this submental splint is 
unnecessary, since the lateral pressure is harmless, especially when the 
interdental splints of gutta percha or of vulcanized rubber are employed. 

In short, while I am prepared to admit that Dr. Bean has by his ap~ 
pareil, and by the application of great mechanical skill, talent, and indus- 
try, treated successfully many cases which, by other appliances and in 
other hands might have resulted most unfortunately, yet it is plain that 
his method will find its field of usefulness in civil practice limited to 
exceptional cases. 

Dr. J. S. Prout, of Brooklyn, New York, has suggested to me a very 
ingenious mode of employing the interdental splint and wire ligature 
conjointly, and which method, at my request, he adopted recently in a 
under my care at Bellevue Hospital. A plate of gutta percha was 
placed upon the top of the teeth across the line of fracture, and this was 
secured in position by silver wire, which had been made to grasp firmly 
the crowns of the adjacent teeth, and was then brought over the horizontal 
gutta-percha plate. In this case it accomplished all that was desired. 

External splints, applied along the base or outside of the jaw. were 
first recommended by Par/-, who used for this purpose Leather; and they 
have been employed in some form, occasionally, by most surgeons. Gen- 



15:2 FRACTURES OF THE LOWER JAW. 

orally they have been composed of flexible materials, such as wetted 
pasteboard, first recommended by Heister, felt, linen saturated with the 
whites of eggs, paste, dextrine, or starch; plaster of Paris has also been 
used: and they have been retained in place by either bandages or the 
sling. As before stated, I have myself used as a sub-mental splint 
gutta percha, and I shall speak of it again as a part of one form of my 
sling dressing. 

Undoubtedly useful, and even necessary in some cases, especially 
where there exists a great tendency to a vertical displacement, they will 
be found, also, in many cases, to render no essential service, and may 
properly enough be dispensed with. 

Whatever objections hold to the use of metallic clasps, must apply in 
some degree to the use of those forms of apparatus in which it is attempted 
to secure the fragments by means of a combination of these clasps with 
outside splints, and in which it is proposed to dispense with all bandages 
or slings, the mouth being permitted to open and close freely during the 
whole treatment. Motion of the jaw cannot be permitted in any case 
where the fracture is far back, since it is then fmpossible to grasp the 
posterior fragment between the two parallel splints. Nothing but com- 
plete immobility of the jaw will now insure immobility to the fracture. 
Some of these forms of apparatus are liable to additional objections, 
which will be readily suggested by an explanation of their mode of con- 
struction. 

Chopart and Desault originated this idea as early as 1780, for frac- 
tures occurring upon both sides: in which cases they advised "bandages 
composed of crotchets of iron or of steel, placed over the teeth, upon the 
alveolar margin, covered with cork or with plates of lead, and fastened 
by thumb-screws to a plate of sheet-iron, or to some other material under 
the jaw." 

The apparatus invented by Rutenick, a German surgeon, in 1799, 
and improved by Kluge, is thus described by Dr. Chester: "It consists, 
1st, of small silver grooves, varying in size according as they are to be 
placed on the incisors or molars, and long enough to extend over the 
crowns of four teeth ; 2d, of a small piece of board, adapted to the lower 
surface of the jaw, and in shape resembling a horseshoe, having at its 
two horns two holes on each side: 3d, of steel hooks of various sizes, 
each having at one extremity an arch for the reception of the lower lip, 
and another smaller for securing it over the silver channels on the teeth, 
and at the other end a screw to pass through the horseshoe splint, and to 
lie secured to it by a nut and a horizontal branch at its lower surface; 
4th, <»f a cap or silk nightcap to remain on the head: and, 5th, of a com- 
press corresponding in shape and size with the splint. The net or cap 
having been placed on the head, and the two straps fastened to it on each 
side, one immediately in front of the ear and the other about three inches 
farther back, which are to retain the splint in its position by passing 
through the two holes in each horn, a silver channel is placed on the 
four teeth nearest to the fracture: on this the small arch of the hook is 
placed, and the screw end. having been passed through a hole in the 
splint. i> screwed firmly to it by the nut, after a compress has been 
placed between the splint and the integuments below the jaw. 



FKACTURES OF THE LOWER JAW 



153 



Fig. 31. 



"If there is a double fracture, two channels and two hooks must, of 
course, be used." 1 

Bush invented a similar apparatus in 18:2:?, 2 , and Houzelot in 1826; 
since which the apparatus has been variously modified by Jousset. Lons- 
dale. Malgaigne, and perhaps others. 

Lonsdale says he has employed his instrument in numerous cases, and 
with complete success. 3 Rutenick succeeded with his apparatus in a case 
where the displacement persisted in spite of all other means. 4 Jousset 
was also successful in two cases.'' Wales, Asst. Surg. U. S. Navy, suc- 
ceeded with an instrument of his own invention. 6 

But others have not been equally fortunate : or, if they have succeeded 
in holding the fragments in apposition, and in securing a bony union, 
other serious accidents have followed. 

In the first case mentioned by Houzelot, the instrument was kept on 
thirteen days, after which an attack of epilepsy deranged everything, and 
the patient was transferred to Bicetre. The second 
patient complained immediately of an intense pain 
under the chin, and a profuse salivation followed. 
These symptoms were subdued by the sixth day, but, 
for some reason, the apparatus was finally removed 
on the tenth day. The fragments thereafter showed 
no tendency to derangement. Seven days after its 
removal, an abscess which had formed under the chin, 
was opened. In the third case the apparatus was 
left in place thirty days, and an abscess formed also 
under the chin. Xeucourt applied it in a double frac- 
ture where the central fragment was much displaced. 
The apposition was well preserved, but he was obliged 
to remove it on the seventeenth day on account of a 
phlegmon which was forming under the chin. The 
patient to whom Bush applied his apparatus would 
wear it but a few days. Malgaigne had the same experience with Bush's 
apparatus. 

In addition to the pain and inflammation, followed by submaxillary 
abscesses, which have been such frequent results of its use, Malgaigne 
has noticed that it is exceedingly inclined to slide forwards and become 
displaced. 

In short, notwithstanding the unqualified testimony of Lonsdale in 
favor of this method of treatment, especially in fractures at the sym- 
physis, and in fractures through any portion of the shaft anterior to the 
masseter muscle, it is, in my judgment, applicable to only a very limited 
number of cases; but if I were to recommend any form of apparatus 
constructed with a view of permitting mobility of the jaws during the 
process of union.it would be that invented by Norman Kingsley, dentist, 




Houzelot's apparatus. 



1 London Med.-Chir. Be v., \ 
1834. 



xw p, 



.471; from Monthly Archives of the Medical 



2 Malgaigne. op. cit., p. 

3 Lonsdale, Practical Treatise "ii Fi 

4 Malg _ ;• . p 396. 
6 Wales, Am. Journ. Me - 



London, 1888, p. 234. 



[bid. p. 896. 



i:>4 



FRACTURES OF THE LOWER JAW 



Fig. 32. 




Plaster model of jaws, 



of this city, and which I have seen used with excellent results at Bellevue 

Hospital. 

Impressions in plaster are first taken of both upper and lower jaws. 
Models made from these impressions will represent the lower jaw broken 
and the fragments displaced. The model of the lower jaw is then sepa- 
rated at the point representing the fracture, and the fragments adjusted 
to the model of the upper jaw. In most cases the position which these 

fragments assume when thus 
placed determines accurately the 
original form and position of the 
lower jaw. Upon the plaster 
model of the lower jaw, obtained 
and rectified in this way, a splint 
or clasp of vulcanite rubber is 
then made, embracing the arms, 
which are made of steel wire, one- 
sixteenth of an inch in diameter. 
The arms must curve upwards a 
little as they emerge from the 
mouth, to avoid pressure upon the 
lips, and then curve backwards, terminating near the angles of the jaw. 
When the apparatus is applied, the teeth must be pushed into the 
sockets of the splint with some force. The dressing is now completed 
by a sling made of strong muslin, extending beneath the chin from one 
arm to the other. 

Dr. Kingsley says, in his late excellent work on " Oral Deformities," 
that he was not aware of the fact until recently that Mr. Hayward, of 
London, had so early as 1858 constructed a similar, but, as I think, less 
perfect apparatus. 1 

George L. Fitch, dentist, California, believes that " dental gutta 
percha " may be made to answer the same purpose as vulcanite rubber, 
in the construction of this and other similar splints. 2 In this opinion, 
however, Dr. Kingsley does not concur. 

The treatment of fractures of the inferior maxilla by a single-headed 
bandage or roller, numbers among its distinguished advocates the names 
of William Gibson and J. Rhea Barton, of Philadelphia. Gibson gives 
the following directions for applying his roller : "A cotton or linen com- 
press, of moderate thickness, reaching from the angle of the jaw nearly 
to the chin, is placed beneath, and held by an assistant, while the surgeon 
takes a roller, four or five yards long, an inch and a half wide, and 
passes it by several successive turns under the jaw, up along the sides 
of the face, and over the head ; now changing the course of the bandage, 
he causes it to pass off at a right angle from the perpendicular cast, and 
to encircle the temple, occiput, and forehead, horizontally, by several 
turns ; finally, to render the whole more secure, several additional hori- 
zontal turns are made around the back of the neck, under the ear, along 



1 " Oral Deformities." "bv Norman W. Kingsley, M.D.S., D.D.S., New York, pp. 
307-300. Appleton, 1880." 

2 Fitch, New York Med. Gazette, 1869. 



FRACTURES OF THE LOWER JAW. 



155 



the base of the jaw. under the point of the chin. To prevent the roller 
from slipping or changing its position, a short pieee may be secured by 




Kiugsley's apparatus applied to model. (From Kingsley.) 

a pin to the horizontal turn that encircles the forehead, and passed back- 
wards along the centre of the head as far as the neck, where it must be 



Fig. 34. 



Fig. 35. 





King-ley's apparatus applied to patient. 
(From Kingsley.) 



Gibson's bandage for a fracturcl jaw. 



tacked to the lower horizontal turn — taking care to fix one or more pins 
at every point at which the roller has crossed." 

Barton employed, also, a compress, and a roller five yards long, the 



156 



FRACTURES OF THE LOWER JAW. 



application of* which is thus described by Sargent: Place the initial ex- 
tremity of the roller upon the occiput, just below its protuberance, and 
conduct the cylinder obliquely over the centre of the left parietal bone to 
the top of the head; thence descend across the right temple and the 
zygomatic arch, and pass beneath the chin to the left side of the face; 
mount over the left zygoma and temple to the summit of the cranium, 
and regain the starting-point at the occiput by traversing obliquely the 
right parietal bone; next wind around the base of the lower jaw on the 
left side to the chin, and thence return to the occiput along the right side 
of the maxilla ; repeat the same course, step by step, until the roller is 
spent, and then confine its terminal end. 

These bandages possess the advantages of being easily obtained, of 
simplicity and facility of application, and, we may add, if considered in 
relation to the majority of simple fractures, of tolerable adaptation to the 
ends proposed. The only objections to their use which I have ever 
noticed are occasional disarrangements, and the tendency, as in all other 
continuous rollers, to draw the fragments to one side or the other, accord- 
ing as the successive turns of the bandage are carried to the right or left. 
There is one other objection, having reference to the occasional inade- 



Fig. 36. 





Barton's bandage for a fractured jaw. 



Four-tailed bandage or sling for the lower jaw. 



quacy of this dressing to prevent an overlapping of the fragments ; to 
which objection also the sling, as usually constructed, is equally obnoxious, 
and of which I shall speak presently. 

!* Finally, it is to the sling, in some of its various forms, with or without 
the interdental splint, that surgeons have generally given the preference. 
The sling is known, also, by the name of the four-headed or the four- 
tailed roller or bandage. 

B. Bell, Boyer, Skey, S. Cooper, B. Cooper, Syme, Fergusson, Mayor, 
Lizars, and Chelius employ the sling, usually ; and the favorite mode is 
to use for this purpose a piece of muslin cloth about one yard long and 
four inches wide, torn down from its extremities to within about three or 



FRACTURES OF THE LOWER JAW. 157 

four inches of the centre. Others have used leather, gutta percha. adhe- 
sive straps, gum-elastic, etc. 

Where the muslin is used, it is quite customary to lay against the skin 
a piece of pasteboard, wetted and moulded to the chin, or simply a soft 
compress : and some choose to open the centre of the bandage sufficiently 
to receive the chin. The middle of this bandage being laid upon the 
chin, the two ends corresponding to the upper margin of the roller are 
now carried across the front of the chin, behind the nape of the neck, 
and made last : whilst the two lower heads are brought directly upwards 
from under the sides of the chin, along the sides of the face, in front of 
the ears, and made fast upon the top of the head. The dressing is com- 
pleted by a short counter-band extending across the top of the head from 
one bandage to the other: or the several bands may be made fast to a 
nightcap, in which case the counter-band will be unnecessary. 

It only remains for me to describe my own method of dressing these 
fractures with the sling. 

Having frequently noticed the tendency of the sling, as ordinarily 
eonstructed, and of Gibson's roller, to carry the anterior fragment back- 
wards, especially in double fracture where the body of the bone is broken 
upon both sides, I devised, some years since, an apparatus intended to 
obviate this objection, and which I have used now many times with entire 
satisfaction. 

It is composed of a firm leather strap, called maxillary, which, passing 
perpendicularly upwards from under the chin, is made to buckle upon 
the top of the head, at a point near the situation of the anterior fontanelle. 
This strap is supported by two counter-straps, made of strong linen web- 
bing, called, respectively, the occipito-frontal and the vertical. The 
occipito-frontal is looped upon the maxillary at a point a little above the 
ears, and may be elevated or depressed at pleasure. The occipital por- 
tion of the strap is then carried backwards, and buckled under the 
occiput, while the frontal portion is buckled across the forehead. The 
vertical strap unites the occipital to the maxillary across the top of the 
head, and prevents the upper part of the latter from becoming displaced 
forwards. At each point where a buckle is used, a pad must be placed 
between the strap and the head. 

The maxillary strap is narrow under the chin, to avoid pressure upon 
the front of the neck, but immediately becomes wider, so as to cover 
the sides of the inferior maxilla and face, after which it gradually dimin- 
ishes, to accommodate the buckle upon the top of the head. The ante- 
rior margin of this band, at the point corresponding to the symphysis 
menti, and for about two inches on each side, is supplied with thread- 
holes, for the purpose of attaching ;i piece of linen, which, when tin- 
apparatus i- in place shall cross in front of the chin, and prevent the 
maxillary strap from sliding backwards against the front of the nock. 

The advantage of this dressing over any which 1 have yet -ecu. con- 
in it- capability to lift the anterior fragment almost vertically, whilst 
at the same time it i> in no danger of foiling forwards, and downwards 
upon the forehead. If. a- in the case of most other dressings, the occi- 
pital stay had its attachment opposite to the chin, it- effect would '»<• t<» 
draw the central fragment backwards. By using a firm piece of leather, 



158 



FRACTURES OF THE LOWER JAW. 



as a in ax ill a rv band, and attaching the occipital stay above the ears, this 
difficulty is completely obviated. 

Having removed such teeth as are much loosened at the point of frac- 
ture, and replaced those which are loosened at other points, unless it be 
far back in the mouth, and adjusted the fragments accurately, the lower 
jaw is to be closed completely upon the upper, and the apparatus snugly 
applied. It is not necessary in most cases to buckle the straps with great 
firmness, since experience has shown that a sufficient degree of immo- 
bility is usually obtained when the apparatus is only moderately tight. 
If the integuments are bruised and tender, a compress made of two or 

more thicknesses of sheet lint should 
be placed underneath the chin, be- 
tween it and the leather. 

If the inability to introduce nourish- 
ment between the teeth when the 
mouth is closed, or the irregularity of 
the dental arcade renders the use of 
interdental splints necessary, gutta 
percha, as I have already explained, 
ought, in general, to be preferred to 
any other material. 

The patient must be forbidden to 
talk or laugh, and when he lies down, 
his head should rest upon its back, 
for whatever mode of dressing is em- 
ployed, and however carefully it is 
applied, it will be found that a slight 
motion and displacement will occur 
whenever the weight of the head rests 
upon the side of the face. 

Occasionally, indeed, as often as 
every two or three days, the apparatus may be loosened or removed, only 
taking care generally not to disturb the interdental splints, when they 
are used, and to support the jaw with the hand, during its removal ; and, 
at the same time, the face may be sponged off with warm water and 
castile soap. It should not be left off entirely, however, in less than 
three or four weeks, even where the fracture is most simple, nor ought 
the patient be allowed to eat meat in less than four or five weeks. 

To cleanse the mouth and prevent offensive accumulations, it should be 
washed several times a day with a solution of tincture of myrrh, prepared 
by adding one drachm to about four ounces of water. 

The same apparatus, and without any essential modification, is appli- 
cable to fractures of the symphysis and of the angle of the inferior max- 
illa, as well as to fractures of the body of the bone. 

Instead of the leather, I have in a few instances, especially of com- 
pound fractures where it became necessary to allow the pus to discharge 
externally, used a sling or a splint composed of gutta percha, suspended 
by bands carried over the top of the head. The piece from which this 
splint is made should be three or four lines in thickness, covered with 
cloth, and padded under the chin. It will be found convenient to cover 




The author's apparatus. 



FRACTURES OF THE LOWER JAW. 159 

it with cloth before immersing it in the hot water. The water should be 
nearly at a boiling temperature, so that the splint may become perfectly 
pliable : and it should be laid upon the face and allowed to mould itself 
while the patient lies upon his back. 

Having thus fitted it accurately to the face, it may be removed and 
openings made at points corresponding with the wounds upon the skin, 
before it is reapplied. 

As has been already explained, the gutta percha, if sufficiently thick, 
and if the lateral wings are allowed to project a little on either side, will 
serve effectually to protect the sides of the face against pressure from the 
bandage ; and being more easily moulded to the base and front of the 
chin than any other material which has yet been employed, must have 
the preference. The necessity for its use, however, is only occasional. 

Dr. S. 0. Yander Poel, Jr., late House Surgeon at Bellevue, has em- 
ployed successfully a modification of my apparatus, made of plaster-of- 
Paris bandage. 1 The apparatus having been applied over a linen night- 
cap, and having been permitted to harden, the maxillary straps are cut 
on a line with the ears, or portions removed and pieces of webbing with 
buckles substituted. The pieces of webbing may be fastened with stitches 
or with plaster. Perhaps it would be quite as well to leave the bandage 
as at first applied until a change becomes necessary — possibly a week or 
two — and then cut and insert the webbing. 

In fractures of either condyle, unaccompanied with displacement, the 
simple leather or muslin sling will sometimes accomplish a perfect and 
speedy cure, as the two cases reported by Desault will sufficiently demon- 
strate. But if the fragments have become separated, the replacement is 
difficult, and the retention uncertain. 

Ribes was the first to suggest and to practise a very ingenious method 
of reduction in these cases. Having seen two examples which had re- 
sulted in deformity under the usual treatment, which consisted in simply 
pressing forwards the angle of the jaw, it occurred to him that when the 
upper or condyloidean fragment was not acted upon at th'e same moment 
by pressure from the opposite direction, a reduction must be impossible. 
The case of a cannoneer whose jaw was broken through the neck of the 
condyle on the right side, and through its body on the left, afforded him 
an opportunity to determine the practicability of a method of which lie 
had as yet only conceived the idea. Malgaigne thus describes his pro- 
cedure : "With the left hand seize the anterior portion of the jaw, for 
the purpose of drawing it horizontally forwards, while you cany the 
index finger of the right hand to the lateral and superior pari of tli< 
pharynx. You will meet at first the projection formed by the styloid 
process, but, moving your finger forwards, you will find soon the poste- 
rior border of the ramus of the jaw; and following tlii< border from 
below upwards, you will arrive at the inner side of the condyle, which 
you will push outward- in such a manner as to engage it upon the other 
fragment. This manoeuvre cannot be made without causing nausea, as 
the finger always doc- when carried into fche posterior pari of the pha- 
rynx ; but this is a slight inconvenience. The reduction obtained, bear 

1 Vander Poel, Archives of Clinical Surgery, Jan. 1. 1878. 



160 FRACTURES OF THE HYOID BONE. 

the jaw upwards and backwards in order to press and fix the condyle 
between it and the glenoid cavity, then fasten it in place with a sling." 
The fragments were thus easily brought into apposition in the case re- 
ported by Ribes, and the patient was cured without any deformity. 

In addition to these means, the angle of the jaw ought to be pressed 
permanently forwards by means of a compress placed between it and the 
mastoid process, and held in place by a suitable bandage; or we may 
adopt the method which proved so successful with Fountain, namely, wire 
the front teeth of the lower jaw to the front teeth of the upper in such a 
manner as to draw the chin forwards, and thus maintain apposition. 

If the coronoid process be alone broken, it is sufficient to close the 
mouth with any form of sling or bandage which may be most convenient. 

In cases of delayed or non-union of the fragments, we may resort to 
the wire ligature, as was practised by myself in certain cases already 
described, or to any other of those expedients described in the chapter on 
General Prognosis. In Dr. Muhlenberg's tables, 14 cases are recorded. 
Of 7 treated by mechanical appliances, 5 were cured, 1 was relieved, and 
1 died ; and of 7 treated by drilling, with its modification, all were reported 
cured. 



CHAPTER XIV. 

FRACTURES OF THE HYOID BONE. 

M. Orfila has reported the case of a man, aged sixty-two years, who 
had been hanged, and whose os hyoides was broken through its body on 
its right side. 1 M. Cazauvieilh has also seen a fracture of this bone in 
two persons who had been hanged, in one of whom the fracture was 
probably in the body of the bone, and in the other through one of its 
cornua. 2 

Lalesque published in the Journal Hebdomadaire for March, 1833, a 
case which occurred in a marine, sixty-seven years old, " who, in a quarrel, 
had his throat violently clinched by the hand of a vigorous adversary. 
At the moment there was very acute pain, and the sensation of a solid 
body breaking. The pain was aggravated by every effort to speak, to 
swallow, or to move the tongue, and when this organ was pushed back- 
wards, deglutition was impossible. The patient could not articulate dis- 
tinctly ; and lie was unable to open his mouth without exciting a great 
deal of pain. He placed his hand upon the anterior and superior part 
of his neck to point out the seat of the injury. This part was slightly 
swollen, and presented on each side small ecchymoses; one above, more 
decided, immediately under the left angle of the lower jaw. The large 
cornu of the os hyoides was very distinctly to the right side, ? ' and it 
could be felt on the left deeply seated by pressing with the fingers; in 

1 Traite de Med. legale, troisieme ed., torn. ii. p. 423. 

2 Cazauvieilh, du Suicide, etc., p. 221. 



FRACTURES OF THE HYOID BONE. 161 

following it in front toward the body of the bone, a very sensible in- 
equality near the point of junction of these two parts could be perceived. 
By putting the finger within the mouth, the same projections and cavities 
inverted could be felt, and even the points of the bone which had pierced 
the mucous membrane, etc.. were evident. Having bled the patient, 
and placed a plug between his teeth to keep the mouth open, the broken 
branch was brought by the finger back to the surface of the body of the 
bone, and easily reduced. The position of the head inclined a little 
back : rest, absolute silence, diet, and some saturnine fomentations, com- 
posed the after-treatment. To avoid a new dislocation by the efforts of 
swallowing, the oesophagus-tube of Desault was introduced, to conduct 
the drinks and liquid aliments into the stomach: this sound w T as allowed 
to remain until the twenty-fifth day; at this time the patient could 
swallow without pain, and began to take a little more solid nourishment, 
and at 'the end of two months the cure was complete. By placing a 
finger within his mouth, a slight nodosity could be felt in the place where, 
in the recent fracture, the splintered points were perceptible. 1 

Dieffenbach has also recorded a fracture of the great right horn, pro- 
duced in the same manner, by grasping the throat between the thumb 
and fingers, which occurred in a girl only nineteen years old. Very 
slight pressure upon the side of the bone was sufficient to move the frag- 
ment inwards, and to produce a crepitus; but it immediately resumed 
its place when the pressure was removed. There being, therefore, no 
displacement, the cure was effected in a short time without resort to any 
remedies except tisans and antiphlogistics. She was not even forbidden 
to speak. 2 

Auberge saw a similar case in a person fifty-five years old, occasioned 
by grasping the throat. The fracture was in the great horn of the right 
side, and the displacement was so complete that crepitus could not be 
felt, and the mucous membrane of the pharynx was penetrated by the 
broken bone. 3 

The following example is reported by Dr. Wood, of Cincinnati. Ohio, 
as having come under his observation in the year 1855: 

••Through the kindness of our friend Dr. P. G. Fore, of this city, we 
were invited to examine a case of fracture of the os hyoides, that had 
occurred about one week before we saw it, in one of his patients. The 
patient was a female, about thirty years of age, who had fallen down the 
cellar steps, striking the prominent parts of the larynx and hyoid bone 
against a projecting brick, severely injuring the larynx as well as frac- 
turing the bone. 

••The fracture was on the left side, and near the junction of the great 
horn with the body of tbe bone. Crepitus was distinctly felt on pressing 
the bone between the thumb and finger; or when the patient would 
swallow: though, at this time, the severe symptoms that followed the 
accident, and continued for several days, had somewhat subsided. 

u Immediately after the accident there was profuse bleeding from the 
fauces, and she experienced great difficulty and pain in the act of swal- 

1 Amer. Journ. Med. Sci., vol. xiii. p. 260. 

1 Medic. Vereinszeitung fur Preussen, is:;:;. \,,. .; : Gazette Med., L884, p. 187. 

3 Revue Med., July, 1- 

11 



162 FRACTUKES OF THE HYOID BONE. 



lowing, and the power of speech was almost entirely lost. On attempt 
ing to depress or protrude the tongue, she felt distressing symptoms 
suffocation. Considerable inflammation and swelling of the throat and 
larynx ensued, and continued in some degree up to the time of our visit. 

"To-day (about four weeks since the accident) Dr. F. informs us that 
the patient has so far recovered as to be able to converse, though the 
voice is somewhat impaired. She is yet unable to swallow solid food, 
and is wholly sustained by fluids." 1 

Marcinkovsky saw a woman in whom both the lower jaw and the left 
horn of the os hyoides were broken by a fall from her carriage against a 
wall. She died in about twenty-four hours, from suffocation. 2 

Dr. Griinder reports the following: 

"A laborer, set. 63, fell from a wagon on his face, and discharged a 
large quantity of blood by the mouth. He found he could not swallow, 
and when seen twelve hours afterward, complained of severe pain in the 
neck and nape, with inability to turn his head, though no injury of the 
vertebrae could be detected. His voice was hoarse and difficult. On 
attempting to drink, the fluid was rejected with violent coughing, the 
patient declaring he felt it as if entering the air-passages. An examina- 
tion of the fauces led to no explanation of this condition. The epiglottis 
did not, however, appear to close completely the larynx, or to be in its 
exact position. The tongue was movable in all directions, and pressing 
it down with a spatula caused no inconvenience. The hyoid seemed to 
possess its continuity. No crepitation or abnormal movability could be 
perceived, and no pain at the root of the tongue occurred on attempting 
to swallow. After repeated examinations, the case was concluded to be 
one in which the functions of the nervus vagus had undergone great dis- 
turbance, or the muscles of the larynx had become torn or paralyzed. 
Medicine and food were administered by means of an elastic tube. The 
patient had a good appetite and slept well; the pain of the neck was 
lost, and its motion recovered; a hectic cough, from which he had long 
suffered, alone remaining. After continuing, however, to go on thus 
well for six days, the cough increased; the appetite failed; strength was 
lost; the voice was scarcely audible; and in five more days the patient 
died exhausted. At the autopsy a fracture of the os hyoides was found. 
One of the large cornua was broken, and had become firmly imbedded 
between the epiglottis and rima glottidis, inducing the raised position of 
the epiglottis, loss of voice, and difficulty in swallowing. The fracture 
was probably produced by muscular action, a cause first assigned in a 
case occurring to Ollivier d' Angers." 3 

I think it more probable that this fracture was the result of a direct 
blow, than of muscular action. In the case referred to, however, as 
having been reported by Ollivier, there can be no doubt that the fracture 
was due to muscular action alone. 

A woman, fifty aix years old, made a misstep and fell backwards, and 
at the same moment that her head was thrown violently back, she felt 

1 Western Lancet; also N. Y. Journ. Med., vol. xv. p. 152. 

2 Medic. Vereinszeitung fur Preussen, 1833, No. 15; Gazette Medicale, 1833, p. 354. 

3 Schmidt's Jahrbuch., vol. lxviii.; also Amer. Journ. Med. Sci., vol. xlix p. 253, 
Jan. 1-852. 



: 

id 



FBACTURES OF THE II YOU) BONE. 163 

distinctly a sensation as if a solid body had broken, in the upper part of 
her neck and upon its left side. An examination showed that she had 
fractured the great left horn of the os hyoides. Inflammation and sup- 
puration followed, and finally, after about three months, the posterior 
fragment made its way out in a condition of necrosis, and the fistula 
promptly healed, but there remained for many years a sense of uneasi- 
ness about these parts when she swallowed, sometimes amounting to pain. 1 

Etiology. — James G. La Roe. of Greenpoint, X. Y., has reported the 
ease oi' a man an. 2~. in whom the right cornu was broken at its junction 
with the body in the act of gaping. During fifteen or twenty days he 
was unable to swallow either liquids or solids, except in very small 
quantities. Complete rest was enjoined, and he was permitted to hold 
his head in that position which he found most comfortable, inclining to 
the right and forwards. He made a complete recovery. 2 

Poinsot has brought together eleven other cases reported by Laugier, 
Rousset, R. Listen, Warren, Obre. Harley, Mackmurdo, Helwig, Sawyer, 
Scharf, and Beck, respectively. An analysis of these latter cases, with 
the eleven cases recorded by me, shows that the fracture was caused by 
hanging, five times; by grasping the throat between the thumb and 
fingers, six times ; by direct blows, eight times : and by muscular action, 
three times. 3 

The observation of Mr. South, that fracture of this bone " is almost 
invariably found" 4 in persons executed by hanging, is probably incorrect, 
since although a large proportion of these subjects are submitted to dis- 
section in this and other countries, yet I know of but these three ex- 
amples which have been published. 

Pathology, Symptomatology, and Diagnosis. — The body of the bone 
seems to have been broken in all of those cases which resulted from 
hanging ; while in all of the other examples the fracture has occurred in 
one of the great horns, or at the junction of the horns with the body. 
Generally the displacement inwards of one of the fragments has been so 
complete that crepitus could not be detected. It was present, however, 
in the examples mentioned by Dieffenbach and Wood. In two instances 
the mucous membrane had been penetrated, and in one the fragment was 
projected between the epiglottis and rima glottidis. 

The accident has been characterized by a sudden sensation as if a bone 
had broken : in a few instances, by profuse bleeding from the fauces; by 
difficulty in opening the mouth ; by impossibility of deglutition, and by 
lose of voice in others: with great pain in moving the tongue, the pain 
being especially at its root ; in one instance the tongue was perceptibly 
drawn to one side. There is usually more or less swelling and soreness 
about the neck, with ecchymosis; and at a later period, cough, expec- 
toration, hoarseness, etc. The circumstances which, however, indicate 
certainly the nature of the accident, are preternatural mobility <>f* the 
fragments, with or without crepitus, and tin- angular inward projection, 

1 Malgaigne, op. 'it , )>. l"-"> 

2 La Roe, MM. Record, April 16, 

Poinsot, Note to French edition of this treatise, i>. l 19. 
1 Note to Chelius'a Surgery, A.mer. ed., vol. i. p. 561. 



164 FRACTURES OF THE PIYOID BONE. 

which may in most cases be distinctly felt in a careful examination of the 
pharynx. 

In the case related by Grunder, the only symptoms were a loss of 
voice, difficulty of deglutition, and a sensation, when the attempt was 
made to swallow, as if the fluids passed into the windpipe; with also an 
imperfect closure of the epiglottis upon the rima glottidis. No preter- 
natural mobility or irregularity in the fragments could be detected, nor 
was there crepitus, and it was concluded that the bone was not broken, 
yet the autopsy showed that the fragment was imbedded deeply between 
the epiglottis and the rima glottidis. 

Prognosis. — It is only in view of its complications that this accident 
can be regarded as serious ; where the severity of the injury has been 
such as to fracture the lower jaw at the same time, as in the case related 
by Marcinkovsk}', or such as to bury the fragment deep in the tissues 
about the rima glottidis, as in the case mentioned by Grunder, a favor- 
able termination could scarcely have been expected. Five of the eleven 
recorded by me have died, but of these, three have died by hanging, and 
the remaining two from the causes named. Of the three in which the 
accident resulted from a direct blow, only the patient of Dr. Fore, of 
Cincinnati, has survived ; while of the three whose fractures resulted 
from lateral pressure upon the cornua all recovered ; so, also, did the two 
patients in whom the fracture was produced by muscular action. 

Treatment. — No doubt when the fragments are displaced an attempt 
ought to be made to replace them by introducing one finger into the 
mouth, while with the opposite hand the fragments are supported from 
without. Lalesque found this a matter of some difficulty, but Auberge 
experienced no difficulty at all. I suspect, however, that the amount of 
difficulty will very much depend upon the degree of displacement, and 
the consequent lacerations of the soft tissues about the bone. But 
however this may be, it must be altogether another thing to be able 
to keep in exact apposition the broken ends of a bone whose diameter is 
so inconsiderable, and upon which it is quite impossible to apply any 
apparatus or dressings to retain the fragments in place. Lalesque threw 
the head of his patient slightly back, with the view of making "perma- 
nent extension" upon the fragments through the action of the muscles 
and ligaments attached to the bone, and he recommends this position as 
that which is best calculated to preserve the coaptation. Malgaigne, on 
the contrary, without having himself seen any example of this fracture, 
believes that the position of flexion of the neck, w T ith entire relaxation of 
the muscles, w 7 ould be most suitable ; and this was the position in which 
La Roe's patient found himself most comfortable. 

In all cases it will be proper to enjoin silence, and to adopt suitable 
measures to combat inflammation ; such as topical bleeding, fomentations, 
moistening the mouth with cool water, or permitting small pieces of ice 
to rest in the mouth until dissolved, without in general allowing the fluid 
to be swallowed ; but in some examples, no doubt, the patient may be 
permitted to swallow. In case the life of the patient is in danger from 
starvation, the surgeon may be compelled to resort to nutritious enemata, 
or possibly to the use of the stomach-tube. The latter method is liable 
to the serious objection that the tube is apt to cause irritation. When 
asphyxia is threatened, laryngotomy or tracheotomy may be demanded. 



THYROID CARTILA'GE. 



165 



CHAPTER XV. 



FKACTURES OF THE CARTILAGES OF THE LARYNX. 

The following summary of 62 cases of fracture of the laryngeal carti- 
lages is compiled from the 52 cases collected by Henocque, and 10 addi- 
tional cases collected by Durham. 1 



Cartilages fractured. 

Thyroid only . 
Cricoid only .... 
Thyroid and os hyoides 
Thyroid and cricoid . 
Thyroid, cricoid, and os hyoides 
Thyroid, cricoid, and trachea 
Cricoid and trachea . 
Cricoid, trachea, and os hyoides 
"Fractures of larvnx " 



No. of 
Cases. 


Deaths. 


Recoveries 


24 


18 


6 


11 


11 




4 


2 


2 


9 


9 




2 


2 




2 


2 




2 


2 




1 


1 




7 


3 


4 



62 



12 



i 1. Thyroid Cartilage. 



M. Ladoz examined the larynx of a man who had been assassinated, 
and upon whose neck he found a handkerchief bound so tightly as to 
leave, after its removal, a deep furrow: but the neck showed also distinct 
marks produced by the fingers and thumb. There was a fracture of the 
thyroid cartilage which extended obliquely downwards, and outwards 
through its right wing. The whole of the larynx was very much ossified, 
although the subject was only thirty seven years old. 2 

In 1823. M. Ollivier communicated to the Academy of Medicine a 
ease in which, this cartilage being broken, the patient died of suffocation. 3 

M. Marjolin says: " Two women at the hospital being engaged in a 
quarrel, one of them seized her antagonist by the throat, and griped her 
so strongly that she broke the thyroid cartilage from its upper to its lower 
margin. You will imagine that it was not very difficult to determine the 
existence of fracture, and that no retentive apparatus was demanded. 
Silence, regimen, a small bleeding, and the cure was accomplished." 4 

Habicott operated successfully, in 1620, by introducing a leaden tube 
into the trachea in ;i case in which the thyroid was "damaged." (Jil»l». 
Norris, Nelaton, and Kenderline have each reported examples of fracture 
of thi- cartilage alone. 5 



1 Durham, Holmes's Surgery, vol. ii. 

2 Gazette Metiicale, L838, }>'. I - 

• Archives Generalee de MeVlecme, tome ii. ]». 807. 

* Marjolin, Coun de Patholog. Chir., p. 396. 

■' Hunt. Prac. of Larvnx, etc. Am. Journ. Med. Sci., April. 1886. 



166 FRACTURES OF THE CARTILAGES OF THE LARYNX. 

In 2-i of the 52 cases collected by Henocque, the thyroid alone was 
broken ; and in 7 of Poinsot's gunshot cases the same fact was observed. 
Poinsot remarks : " In all the cases of fracture of the thyroid alone noted 
by Henocque, the fracture was produced by lateral pressure, the larynx 
having been violently squeezed between the thumb and fingers. In the 
cases of Piedagorel and Martin-Damourette, the same cause existed. 
Sometimes, however, the fracture seems to have been produced by a direct 
pressure from before backwards. Such was a case reported by Mr. 
Langlet, where an insane man suffered with this fracture, which had been 
caused by the pressure of the edge of a strait-jacket. 

wk Henocque, and after him Chailloux, insists upon the fact that fracture 
of the thyroid cartilage, whether isolated or not, has never been observed 
to follow hanging. 

" Contrary to what occurs in the case of the hyoid bone, fractures of 
the thyroid cartilage, whether produced by pressure either lateral or from 
before backwards, are of a grave character. Out of his 23 cases, 
Henocque counts no less than 18 deaths. 

wt As a singular contrast, in gunshot fractures the results are less dis- 
astrous ; our seven cases only count two deaths, and in these two the 
fatal termination is explained by the extent of the accompanying lesions. 
In one of the wounded, the ball, after entering near the symphysis mentis, 
had broken the jaw, had passed under the hyoid bone, and had lodged 
itself in the thyroid cartilage. In the other, beside the loss of a portion 
of the anterior part of the thyroid cartilage, the autopsy showed a fracture 
of the humerus, of the left clavicle and shoulder-blade, and of the right 
side of the lower jaw. 

kt Of the four wounded who recovered, two were operated upon by 
tracheotomy. In the one operated upon by Maas, a Chassepot ball 
having fractured the left ala of the thyroid cartilage, considerable emphy- 
sema of the neck and chest supervened within a few moments, the blood 
flowing into the trachea. Maas performed superior tracheotomy during 
a severe paroxysm of asphyxia, and the patient recovered without any 
accident. Muller only operated on his patient on the second day, when 
there existed some cyanosis, resulting from dyspnoea, and a well-marked 
infiltration of the neighboring tissues ; the cure was accomplished also 
without any untoward event. 

"Goetting's patient, who had both lamellae of the thyroid cartilage 
traversed through their middle and from right to left by a Chassepot ball, 
exhibited, as soon as wounded, symptoms of suffocation which he thought 
would prove fatal, but these phenomena subsided entirely before he was 
placed in the ambulance, and he recovered without operative interference. 
In the case of Fischer's patient, no accident occurred; indeed, there was 
only an incomplete fracture, the projectile having only taken off the 
most superficial lamellae of the pomum Adami. But in our last case, the 
cure was no less exempt from complications, although, as in Goetting's 
patient, the ball had traversed the thyroid cartilage and had wounded the 
vocal cords. The patient breathed freely through the wound, and at no 
time were there any symptoms of suffocation. The edges of the wound 
were approximated by means of a silver suture, and it was healed in two 
months." 1 

1 Poinsot, French edition of this trontiso. p. 152. 



THYROID AND CRICOID CARTILAGES. 167 



§ 2. Thyroid and Cricoid Cartilages. 

Plenck saw a fracture of both the thyroid and cricoid cartilages pro- 
duced by falling upon the rim of a pail. 1 Morgagni also says that he 
had seen fractures of the larynx : and Reiner mentions a fracture of the 
larynx found in a person who had been hanged: 2 but in neither case is 
it said in which cartilage the fracture occurred, or whether it had not 
oecurred in both. 

Dr. O'Brian, of Edinburgh, 3 reports a case of fracture of both carti- 
lages, involving the trachea also, in a woman avIio had received a kick 
under the jaw. and who died on the following day. Several additional 
examples have been reported by other surgeons, as will be seen by refer- 
ence to the table at the head of this chapter. 

I am able to furnish, from my own observation, one example of frac- 
ture of both the thyroid and cricoid cartilages. 

John Calkins, of Collins, Erie Co., N. Y.. set. 41, is supposed to have 
been kicked by a young horse on the 10th of November, 1856. He was 
alone in the stable when the accident occurred, and, being stunned by 
the blow, he could not himself give any account of the manner in which 
the injury was received. When found, he was sitting upright, but un- 
able to articulate except in a whisper. Drs. Barber and Davis, of Colden, 
saw him about two hours after. His countenance was anxious, his pulse 
feeble, extremities cold, and he was breathing with great difficulty. A 
small quantity of blood was issuing from his fauces. His upper lip was 
cut. and a few of his teeth dislocated: the wound appearing as if inflicted 
by <>ne of the corks of the horse's shoes. There was no other wound; 
but over the left wing of the thyroid cartilage there was a slight discolor- 
ation, pressure upon which produced intense pain and suffocation, and 
disclosed the fact that the thyroid prominence was depressed very much 
and broken. Cold lotions were directed to be applied, and as the thirst 
was excessive, but deglutition impossible, he was permitted to hold pieces 
of ice in his mouth. This plan, with but slight modifications, such as 
the substitution of warm fomentations to the neck for the cold lotions, 
was continued until the following evening, when, at the request of the 
attending physician, Dr. Barber, I was called to see him. The symp- 
toms remained nearly the same as at first. He was unable to speak 
audibly, or perform the act of deglutition: his breathing was difficult, 
and at times threatened suffocation. The lateness of the hour, with other 
circumstances, determined me to defer surgical interference until morn- 
ing. At daybreak of the 12th. T made the operation of laryngotomy, 
and introduced a large double canula into the crico-thyroidean space. 
This operation was rendered difficult by the great amounl of -welling 
about the neck, due both to emphysema, and bloody, with -('1011-. infil- 
trations. The breathing Immediately became easy, and gradually the 
appearance of asphyxia disappeared from lii- face; but, after about six 

1 Rfalgaigne, <>\>. fit . p. L09. 

1 Morgagni, de Sedibus, etc., Epw. 19, num. 13, 14, el 16; Remer Annalee d'Hy- 
gidne, tome iv. p, 171 ; from Blalgaigne. 
8 O'Brian. Edinburgh Med. and Surg. Journ., vol. 1*. 



168 FRACTURES OF THE CARTILAGES OF THE LARYNX. 

or Beven hours, he began perceptibly to fail in strength, and died at 3 
o'clock P. m. of the following day, apparently from exhaustion rather 
than from suffocation, having survived the accident about seventy-two 
hours, and the operation about thirty-four hours. 

The autopsy disclosed a comminuted fracture of the thyroid cartilage, 
with a simple fracture of the cricoid. The thyroid was broken almost 
perpendicularly through the centre, the line of fracture being irregular, 
and inclining slightly to the left side. The left inferior horn was broken 
off about three lines from its articulation with the cricoid cartilage. The 
right ala was broken also in a line nearly vertical, but irregular, at a 
point about six lines from its posterior margin. The pomum Adami 
was depressed to the level of the cricoid cartilage, and the left ala, being 
completely detached, was thrown inwards and upwards several lines. 
Underneath the perichondrium, especially upon the inner side, there 
was pretty extensive bloody infiltration. Ossification of the cartilages 
had commenced at several points, but it had made little progress. 
The central fracture of the thyroid was through cartilage alone. The 
fracture of the right ala was through cartilage until it reached a bony 
bell comprising the two inferior lines of its course. The left lower horn 
was ossified, and the fracture was through this bony structure. The 
fracture through the cricoid cartilage commenced close upon the margin 
of a bony plate, but in its whole course it traversed only cartilage. It 
was on the left side. There was also an incomplete fracture on the 
right ala of the thyroid cartilage, commencing in the line of the principal 
fracture and extending obliquely downwards about three lines, until it 
was arrested by the bony plate which constituted the lower margin of 
this wing. 

A ragged, lacerated wound in the back of the larynx, above the cricoid 
cartilages, communicated directly with the oesophagus. 

§ 3. Cricoid Cartilage. 

Both Valsalva and Cazauvieilh have each met with a single example 
of this fracture, without fracture of the thyroid cartilage; and Weiss has 
found the cricoid cartilage broken into numerous fragments, and at the 
same time separated from the trachea. 1 In the table at the beginning of 
this chapter, eleven similar cases are recorded. 

General Etiology of Fractures of the Laryngeal Cartilages. 
— As a predisposing cause, advanced age, with its usual concomitant, 
partial or complete ossification of the cartilages, has been thought to 
occupy a prominent place. In the case reported by Plenck, the carti- 
lages were already very much ossified, although the subject was only 
thirty-seven years old. Morgagni observed that in his experience it had 
occurred always in advanced life. In my own case, however, the carti- 
lages were only slightly ossified, the patient being forty-one years old; 
nor did the lines of* the several fractures indicate a preference for the 
bony plates: but it seems to me that they rather avoided them, and in 

1 Malgaigne, op. cit., p. 408. 



CRICOID CAETILAGE. 169 

the case of the incomplete fracture the bone appeared to have arrestee! 
the fracture. In fact, a few experiments have satisfied me that the adult 
laryngeal cartilages are quite as brittle as bene, and. consequently, that 
ossification in no way increases their liability to fracture. 

Hunt ascertained the age in fifteen cases, and but one of the whole 
number was oyer 45 years: five occurred in children, one of whom was 
only four years old. 

The immediate causes have been direct blows, as falling upon the edge 
of a pail, a kick from a horse, or pressure, as in hanging, or in grasping 
the larynx strongly between the thumb and fingers, and in gunshol 
injuries. 

Gexeral Symptomatology. Etc. — The signs of tins accident are such 
as may attend any severe injury of this organ, whether accompanied 
with a fracture or not. such as pain, swelling, difficult deglutition, em- 
barrassed respiration, loss of voice, cough, and perhaps bloody expecto- 
ration, with emphysema, etc. 

But none of those can be regarded as diagnostic : although, when 
taken in connection with the history of the accident, especially if a very 
severe and direct blow lias been received, or more certainly still when 
symptoms so grave and complicated have followed an attempt at strangu- 
lation by grasping the throat, they may be regarded as probable or pre- 
sumptive evidences. 

A positive diagnosis must depend upon the presence of a sensible dis- 
placement, or motion of the fragment-, with crepitus. 

In the case related by Plenck, death followed almost immediately, 
with convulsions, and without any outcry : indicating, probably, some 
severe lesion of the spinal marrow ; whilst in M. Ollivier's patient >ufib- 
cation ensued, at first intermittent, and finally permanent. 

Gurlt reports 12 examples of sudden death following these lesions, of 
which he thinks at least 3 were unaccompanied by lesion of the spinal 
cord. 

In my own case, suffocation was throughout a prominent symptom, 
with only such slight intervals of amelioration as might have been occa- 
sioned by the extrication of the blood or mucus from the larynx. 

General Prognosis. — The prognosis ought to depend rather upon 
the seat, complications, and gravity of the injury, than upon the simple 
decision of the question of fracture A fracture produced by grasping 
the wings of the thyroid cartilage, and without any great contusion or 
laceration of the soft part.-, might reasonably be expected to terminate 
favorably under judicious management; hut when, on the contrary, the 
fracture is the result of great violence inflicted directly upon the front of 
the cartilages, producing severe contusion and laceration, and is followed 
by great -welling, emphysema, very difficult respiration, complete aphonia, 
impossibility of deglutition, etc. the prognosis cannot but be unfavorable. 

By reference to the table at the beginning of thia chapter it will be 
seen" that all of the cases — 'i~ in number — in which the cricoid was in- 
volved, terminated fatally. The only cases involving the cricoid in which 
recovery has taken place have been certain examples of gunshot injuries. 



170 FRACTURES OF THE CARTILAGES OF THE LARYNX. 

(,i \i km. Treatment. — In examples of simple, uncomplicated frac- 
ture, "silence, regimen, and a small bleeding" may suffice; but in other 
casee if may become necessary to introduce a tube into the stomach, to 
supplj the patient with food and drink, since deglutition may be impos- 
sible. It", also, Buffbcation is imminent, there may remain no alternative 
hut a resoii to tracheotomy. Indeed this operation ought, we think to 
be resorted t<> in all cases in which emphysema is prominent, or in which 
respiration is interfered with Beriously. Dr. William Hunt, of the Penn- 
sylvania Hospital, in his excellent paper on " Fractures of the Larynx 
and Ruptures of the Trachea." in which he has arranged a tabular 
synopsis of twenty-nine cases, Bays that of seventy-seven cases ten re- 
covered and seventeen died. Of eight cases in which tracheotomy was 
peiti. lined, but two died. In the four cases in which recovery took place 
without an operation, no mention is made of bloody expectoration or of 
emphysema. 1 

As to a ••reduction" of the fragments by manipulation, I believe it 
will be found generally, if not always, impracticable. Whatever dis- 
placement exists must he mostly inwards, and we can have no means of 
forcing them again outwards. Nor, if once replaced,' do I see any reason 
to Buppose that they would not become immediately displaced. 

Chelius has suggested the propriety, in such cases, of cutting open 
the coverings of the larynx freely in the median line, and, after stanching 
the bleeding, proceeding at once to divide the larynx itself in its whole 
length, and then replacing the broken cartilages. 2 The procedure has 
an aspect of severity, but I can well conceive of circumstances which 
would justify its adoption : not, however, so much for the purpose of re- 
placing the cartilages, as for the purpose of arresting a fatal internal 
haemorrhage, and of giving a free admission of air to the lungs. If this 
operation were to be practised, the wound ought to be left open for a 
sufficient length of time to allow of the subsidence of the inflammation, 
and then permitted to close with such precautions as experience teaches 
are usually necessary after the windpipe has been opened. 

Antiphlogistic measures, combined with fomentations to the neck, so 
fur ;i» these Latter are found to be agreeable and practicable, are important 
measures, and not to be overlooked in the general plan of treatment. 

My own patient, also, found small pieces of ice, permitted slowly to 
dissolve in the mouth, very grateful : but he preferred very much, as an 
externa] application, the warm fomentations to the cold lotions. 

Note.— -Additional references: Fractures of the Larynx. Gurlt, der Knochen, 

vol.2. Helwig. Casper's Viertelj., 1861, p. 342. Witte, Archiv fur Klin. chir. 

abeck, Bd 21, 8. 194 7. 503. Fischer, Krico-Brf., 1 Theil Hets., S. 113. 

rfer, ffand-b.. der Kniegs, 2 Baffte, 2 Heft, S. 419. Henocque, Gaz. Hebdom., 

Oct 2, 1868. Fredet, Bur. Frac. du Larynx, 1868. Gaz. des Hop.^ 

Oand 91. Chaillouz, These '1" Paris, 1873. Wales, Am. Journ. Med. 

B61. Hamilton, Ibid., April, 1867. O'Brian, Ed. Med. and Surg. Journ., 

\n:.t .. Dec. 1866. Keiller, Edin. Med. Journ., 1856, pp!~ 527, 824. 

Dublin Q irt, May, I860. Lancet, 1869, p. 707. 

1 Hunt. Amer. Journ. Med Sci . April, 1866. 

stem of Surgery, Philadelphia ed., vol. i. p. 581, 1847. 



FRACTURES OF THE SPINOUS PROCESSES. 



171 



CHAPTER XVI. 



FRACTURES OF THE VERTEBRAE. 

It will be convenient to divide fractures of the vertebrae into fractures 

of the spinous processes, transverse processes, vertebral arches, and 
bodies. 

§ 1. Fractures of the Spinous Processes. 

Fractures of the spinous apophyses, independent of a fracture of the 
arches, may occur at any point of the vertebral column : and they may 

be occasioned by a blow received upon either side of the spinal column : 
or by a force directed from above or from below. 

Symptoms and Pathology. — These accidents may be recognized by 
the lively pain at the point of fracture, produced especially when the 
patient bends forwards, which position renders the skin and muscles 
tense and drives the fragments into the flesh: by the swelling, tender- 
ness, and discoloration : but chiefly by the lateral displacement of the 
broken process, and the mobility. 

Duverney met with a fracture of two of the processes in the same 
person, and which could only be recognized by the mobility, since, .1^ 
the autopsy proved, there was no displace- 
ment. Xor would it be surprising if the 
displacement was absent in a majority of 
these accidents, inasmuch as the attach- 
ment of the ligaments from above and 
below with the strong and short muscles 
upon either side, must prevent a deviation 
in any direction until these tissues are 
more or less torn. Sir Astley Cooper 
mention- a case in which, however, such 
lacerations did occur, and the lateral de- 
formity was quite conspicuous. 

A boy had been endeavoring to support 
a heavy weight upon his shoulders, when 
he fell, bent double. Immediately he had 
the appearance of one suffering under a 
distortion of the spine of long standing. 

Three or four of the processes were broken off. and the corresponding 
muscles were detached so as to allow the processes to fall oil" to the oppo- 
site side. There was no paralysis, and he was soon discharged with the 
free nse of his limbs, but the deformity remained. 1 




Fracture of the spinous | 



1 Sir Astley Cooper, op. ':it.. p. t69. 



17 'J FRACTURBS OF THE VERTEBH.K. 

[f the fragment is thrown directly downwards, as it possibly may be, 
especially in the cervical or lumbar region, yet not without a rupture of 
the supraspinous ligaments, or of the ligamentum nuchse, then the dis- 
placemenl will be more difficult to detect, and it may require some more 
care QOf to confound it with a fracture of the vertebral arch or of the 
plates from which the spinous processes arise. The process not being 
fell in its natural position, nor upon either side, it may seem to have 
been forced directly forwards, when, in fact, it is only thrown downwards 
towards its fellow. The danger of error in the diagnosis will be increased 
when to these conditions is added paralysis of those portions of the 
body which are below the seat of the fracture, and which, in this case, 
may be the result of an extravasation of blood or of simply a concussion 
of the Bpinal marrow. Nor do I think it would be possible now to deter- 
mine positively whether it was simply a fracture of a spinous process, of 
the arch, or of the body itself of the vertebra. In case, however, the 
paralysis results from concussion, the fact will in most cases soon become 
apparent by a return of sensation and of the power of motion. 

Prognosis. — Hippocrates affirmed that here, as in fractures of other 
spongy hones, the union took place speedily. It is quite probable that 
tEus venerable father of surgery has stated the fact correctly, and yet in 
the only example known to me where the condition of this process, as 
proved by dissection, lias been carefully stated, the fragment had not 
united by bone at all. This is the case related by Sir Astley Cooper as 
having been examined by Mr. Key. A subject was brought into the 
dissecting-room, in which one of the processes had been broken, and, on 
dissection, a complete articulation was found between the broken sur- 
face-, which surfaces had become covered with a thin layer of cartilage. 
The false articulation w r as surrounded with synovial membrane and cap- 
sular ligaments, and contained a fluid like synovia. 1 

Ordinarily the displacement continues, whatever treatment may be 
adopted; but Malgaigne says he has seen one instance in which the 
twelfth dorsal spine, being broken and displaced laterally, resumed its 
place spontaneously after a few days. Aurran mentions a similar ex- 
ample. 

Treatment. — If in any case it should be found possible to act upon 
the fragment, an attempt might be made to press it into place, and to 
retain it there by means of a compress and bandage; but even this would 
not he admissible so long as any doubt remained whether it was not a 
fracture of the vertebral arch, since, if it were, any attempt to restore 
the bone to place by pressure would be likely to drive it more deeply 
upon the Bpinal marrow. Yet what need is there of surgical interference 
of any kind? If the apophysis remains displaced, it cannot result in 
any serious, perhaps we may say in any appreciable deformity. The 
surgeon has therefore only to lav the patient quietly in bed, and in such a 
position as he find- most comfortable, enjoining upon him perfect rest, and 
employing such other means as may be proper to combat inflammation. 

1 Sir Astlej Cooper, op. 'it.. j>. 159. 2 Malgaigne, op. cit, p. 412. 



FRACTURES OF THE TRANSVERSE PROCESS. 173 



§ 2. Fractures of the Transverse Process. 

A fracture of a transverse process can scarcely occur except as a con- 
sequence of a gunshot wound. Dupuytren relates a ease of this kind 
in which the ball had penetrated the transverse process of the second 
cervical vertebra. The man bled very little at the time, and his symp- 
toms progressed favorably for ten days; after which, secondary haemor- 
rhage occurred, of which he ultimately died. The autopsy showed that 
the vertebral artery had been injured, and that the inflammation of its 
coats being followed by a slough, caused his death. 1 

I have also elsewhere reported the case of Charles Harkner, of Buffalo, 
N. Y.. who was shot with a pistol on the 21s1 of January, 1851. 1 did 
not see him until the following day. The ball had entered the chin, a 
little to the left side and below the inferior maxilla, but its place of lodge- 
ment could not be discovered. He lay with his face constantly tinned 
to the right. The left side of his neck was swollen and crepitant; the 
left arm and leg were paralyzed; he slept most of the time, but could be 
easily aroused, and when aroused he seemed to be conscious, but was 
unable to speak. By signs he indicated to us that he was suffering no 
pain. He gradually sank, without haemorrhage, and died in thirty-six 
hours from the time of the receipt of the injury. 

The autopsy, made four hours after death, enabled us to trace the 
wound from the chin, through the left ala of the thyroid cartilage, and 
also through the roots of the transverse process of the fourth cervical 
vertebra : immediately behind which, lying imbedded in the muscles, 
was the bullet. The cavity of the tunica arachnoides contained consid- 
erable serous effusion. 

The emphysema in the neck was occasioned, no doubt, by the wound 
of the larynx, the ball having opened freely into its cavity. This cir- 
cumstance also explained the aphonia : but the immediate cause of his 
death seems to have been arachnoid effusion as a result of meningeal in- 
flammation. 

The symptoms arising from this accident can only refer to the compli- 
cations, since a mere fracture of the process is not likely to present any 
peculiar signs which could be recognized. Concussion or bloody*effusion 
may take place so a- t<> occasion more or less paralysis, or, at ;i later 
period, inflammation and its consequent effusions maj give rise to the 
same phenomenon. 

In itself considered, and independent of these complications, it is suffi- 
ciently trivial, but inasmuch as it has not been known to occur except 
from gunshot wounds, nor is it likely to occur except from penetrating 
wound- of some kind, the accident must always be regarded as exceed- 
ingly grave, if not actually fatal. 

As to the treatment, nothing hut strict rest and antiphlogistic remedies 
can prove of any service. 

1 Dupuytren, Diseases, ete.^ of Bon< a, 8yd. ed., p. 860. 



174 



FRACTURES OF THE VERTEBRAE. 



§ 3. Fractures of the Vertebral Arches. 



Fig 10. 



The vertebral arches, upon which both the spinous and transverse 
processes have their principal support, may be broken at any point of 
their circumference, by a blow received upon the spinous process; but 
generally it is the lamellar portion, or the "vertebral plate" which gives 
wav rather than the neck or pedicle of the arch ; and in nearly all of the 
cases recorded the plates have been broken upon both sides. The only 
exception to this rule, of which the author is informed, is the specimen 
said to be in the museum of Val-de- 
Grrace, and mentioned by M. Lequest. 1 

On the first of May, 1851, during a vio- 
lent storm of wind and rain, a balustrade 
fell from the top of a high building, strik- 
ing a man named John Larkin, who w T as 
about forty years of age, upon the back of 
his head and neck. He fell to the ground 
instantly, and did not again move his feet 
or legs, although he never lost his con- 
sciousness until he died. I found the blad- 
der paralyzed also, and his left arm, but 
his right arm he could move pretty well. 
He conversed freely up to the last mo- 
ment, and said that he was suffering a 
good deal of pain, which was always 
greatly aggravated by moving. His death 
t<»<»k place thirty-six hours after the receipt of the injury. 

Dr. Hugh B. Vandeventer, who was the attending surgeon, made a 
dissection on the following day in my presence, which disclosed the fact 
that the plates of the sixth cervical vertebra were broken upon each side, 
and thai the spinous process, with a small portion of the arch attached, 
was forced in upon the spinal marrow. There was no blood effused or 
-••nun ;it this point, but a bout one ounce of serum was found in the cavity 
of the tunica arachnoides at the base of the brain. The bodies of the 
rertebrfc were doI broken. It was our opinion, therefore, that the imme- 
diate cause of his death was the direct pressure of the spinous process. 

In the case related by Prout, of Alabama, the man having died within 
forty-eighl boms after the receipl of the injury, the arch of the fifth cer- 
vical vertebra was Pound to be broken in three places, and the spinous 
process was driven in upon the spinal marrow. There was a slight 
effusion of blood between the sheath of the spinal marrow and the bone, 
and a considerable effusion between the sheath and the cord. There was 
do material lesion of the cord or of its membranes, and the body of the 
bone was neither broken nor dislocated.-' 

It is probable, also, thai iii the following example the arch was broken, 




Fracture <>f the vertebral arch. 



■ M . Lequest, Die. Encyc., 3d Series, vol. i. p. 446. 
Prout, Ain't-. Journ. Hied. Sci., Nov. 1837, vol. xxi. p. 276, from Western Journ. 
Med. and Phys. 8ei. 



FRACTURES OF THE VERTEBRAL ARCHES. 175 

but that the force of the blow having been somewhat oblique, the process 
was but little if at all thrown in upon the spinal marrow. 

K. L., of Erie County, N. Y.. aged about forty years, was thrown 
from a loaded wagon in February of 1851, striking, as he thinks, upon 
the back of his neck. He was stunned by the injury, and remained 
insensible several hours: on the return of consciousness, he found that 
his lower extremities and bladder were paralyzed. During four weeks 
bis bladder had to be emptied by a catheter. Nine months after the 
injury was received he consulted me, and I found the spinous process of 
the last cervical vertebra pushed over to the lefl aide. His head was 
strongly bent forwards, and lie was unable to straighten it. He could 
walk a few steps, but not without great fatigue: and he suffered almost 
constant pain in his lower extremities, accompanied with excessive rest- 
lessness and watchfulness, for which he was obliged to take morphine in 
large quantities. 

In the case related by Alban Gr. Smith, of Kentucky, to which I shall 
refer again presently, the deviation was lateral, and so also in Ollivier's 
case, mentioned by Malgaigne. 

Symptoms. — We can imagine a case of fracture of the vertebral arch, 
with a lateral displacement only, in which the symptoms might not differ 
essentially from a simple fracture of the spinous process; and it is quite 
possible that some of the cases which have been supposed to be examples 
of this latter accident, and in which a speedy recovery lias taken place. 
were really examples of fractures of the arches: yet it must be admitted 
chat such a fortunate result is only possible, since the arches can hardly 
be broken without communicating a severe concussion to the marrow, 
nor without lacerations, inflammation, and effusions, which will be mosl 
certain to produce compression and paralysis, and probably death. 

If, however, it is possible for us to confound a fracture of the process 
with a fracture of the arches, it i> still more possible to confound a 
fracture of the arches with a fracture of the bodies of the vertebrae. 
If, as is usually the fact, the process, in case of a fracture of the arch, 
is Less prominent than natural, and that portion of the body receiving it- 
nervous supply from below this joint is paralyzed, we may have reasons 
to believe that the arch is broken and the process is driven in upon the 
spine; but dissections have shown that in many of these cases, <>)• in 
most of them, indeed, the bodies of one <>)• more of the vertebras are 
broken also, and in still other cases the bodies alone were broken. 

If. as in the case mentioned by Ollivier, we can feel the plates move 
separately, the diagnosis might be made out. so far ;it least a- to deter- 
mine that the plates were broken; but we would be still unable t-i sa) 
that the bodies of the vertebrae were not broken also. 

Something, perhaps, may be inferred from the direction and manner 
of the blow which has produced the fracture. Thus, ;i fall upon the top 
of the head, the feet, or the nates, would most often produce a comminu- 
tion of the bodies by crushing them together, whilst a blow upon the buck 
could scarcely break one of the vertebrae without breaking the corre- 
sponding arch also. We might thus !><• led to infer, in the first instance, 
that the arches were not broken: and, in the second instance, if we could 



176 FRACTURES oV THE VERTEBRJE. 

convince ourselves that the arches were not broken, we might rest pretty 
well assured thai the bodies were not. 

In the case related by Prout, there was no external mark of injury 
over the poinl of fracture, bul a distinct crepitus was perceptible on 

pre— lire. 

Treatment. — It' the fragments are not displaced, nothing but rest and 
i cooling regimen are indicated: but if they are forced in upon the marrow, 
an important question is presented, and which has received from different 
surgeons difFerenl solutions. Shall an effort be made to reduce the frag- 
ment-': and, if so. by what means shall the indication be attempted? 

It will be remembered that in nearly all of these cases we must remain 
in doubt, even after the most careful examination, as to the actual condi- 
tion of the fracture. It may be that what we suppose to be a fracture 
of the arch is only a fracture of the apophysis, or that, on the other 
hand, it is a fracture of the body of the bone itself; and if we are 
expert enough to make out clearly a fracture of the arch, it is not possible 
for us to Bay that the body is not broken also, indeed it is quite probable 
that it is broken. With a diagnosis so uncertain, can we ever find a 
justification for surgical interference? Mr. Cline and Mr. Cooper 
thought that we might. According to them, the case presents in no 
other direction a point of hope or encouragement. Death is inevitable, 
-..oner or later, if the fragment is not lifted, and we can scarcely make 
the matter any worse by interference. If it proves to be a fracture of 
the apophysis, as happened to be the case in a patient upon whom Sir 
A-th\ operated. 1 our interference was unnecessary, but it has done no 
harm. It' the body of rhe bone is broken, the operation affords no 
resources, but the patient is probably beyond suffering damage at our 
hands. If the diagnosis is correctly made out and the arch only is 
broken, and if. ;i- was the fact in the case of Larkin already mentioned, 
there ifi no bloody effusion, or laceration of the membranes or of the 
marrow, and if the concussion was not sufficient to determine much 
inflammation of the cord, then it would seem possible that an operation 
might save the patient. 

Tallin- ^Egineta first suggested that the compressing fragments ought 
to l.e removed by excision: and in 1762 Louis removed from a man who 
had received ;i gunshot wound in his back, after the lapse of five days, 
several loose piece- of hone belonging to the arch of the vertebra, and 
the patient recovered, hut not without a partial paralysis of his lower 
extremities. Of course, nothing could be more rational or simple than 
this procedure, adopted by Louis, in any case of an open wound, where 
the fragments could be easily readied: but the younger Cline was the 
first, in the year 1*14. to put into practice t lie more ancient suggestion 
of Paulus jEgineta, namely, to attempt the removal of the fragments in 
;i case of simple fracture. He made an incision upon the depressed 
bones a- the patient was lying upon his face, raised the muscles covering 
the spinal arch, removing, by means of a circular saw, chisel, mallet, 
trephine, etc.. the spinous processes of the eleventh and twelfth dorsal 
vertebra, and the arch of one of the vertebrae. The patient was in no 

1 Chelius'fl Surgery, Amer, ed., note by South, vol. i. p. 592. 



FRACTURES OF THE VERTEBRAL ARCHES. 177 

manner relieved, and died on the fourth day after the receipt of the 
injury and the third after the operation. 1 Mr. Oldknow repeated this 
operation in 1819 in a case of fracture of the arch of the seventh vertebra* 
The patient died on the sixth day.- In 1822, Mr. Tyrrell operated at 
St. Thomas's Hospital on a man who had been injured four days pre- 
viously, removing the spinous processes of the twelfth dorsal and first 
lumbar vertebrae. The operation was accomplished with considerable 
difficulty, and resulted in only a partial return of sensibility, lie died 
on the thirteenth day after the operation. 3 In 1827, Tyrrell operated a 
second time, and death resulted on the eighth day. 4 On the 30th of 
August, 1824, Dr. J. Rhea Barton, of Philadelphia, operated upon a 
man who had been received into the Pennsylvania Hospital twelve days 
before, with a fracture of the arch of the seventh dorsal vertebra. On 
the third day he was attacked with a violent chill, and death took place 
twelve hours after. The dissection showed about half a gallon of blood 
in the posterior mediastinum, and bloody effusion existed along the whole 
length of the spinal canal. 5 The patient whom Laugier trephined at the 
base of the spinous process of the ninth dorsal vertebra, died on the 
fourth day. 6 The operation has been repeated unsuccessfully by Wick- 
ham, Attenburrow, Holcher, Heine, and Roux. 7 

February 5, 183-4, Dr. David L. Rogers, of New York, operated upon 
a man who had fallen two days before, breaking the arch of the firsl 
lumbar vertebra, and forcing the spinous process upon the cord. This 
man died on the eighth day/ 

In 185-1 Dr. Blackman, of Cincinnati, operated, his patient dying on 
the fourth day. During the same year, also, Dr. B. removed a portion 
of the sacrum for an injury of four years' standing, with no benefit. 9 
In 1858 Dr. Stephen Smith, of Bellevue, removed the arch of the tenth 
dorsal vertebra, deatli occurring soon after. 10 December '2\K 1857, ten 
days after the receipt of the injury, Dr. J. C. Hutchison, of Brooklyn, 
operated upon a man at the City Hospital, Brooklyn, removing the 
spinous processes of the eighth, ninth, and tenth dorsal vertebrae, with 
the posterior arch of the latter. The patient survived the operation ten 
days. 11 Ballingall Bays Dr. Blair is reported in the Essays of Dr. 
Monro. Secundus, as having operated successfully, but no particulars are 
given by Ballingall. 12 

Dr. H. A. Potter. <>\' Geneva, X. Y.. Informs us that he ha- operated 
three time-. In the firsl case ho states that he removed the posterior 

portion of tin- three lower cervical vertehr;«\ The patient died OB the 

1 Cline, Chelius'a Surgery, Amer. ed., vol. i. p. 590. 

2 Oldknow, Sir A. Cooper on Disloc. and Frac., Amer. ed., L861, p. 17'.'. 

3 Sir A. Cooper's Lectures, by Tyrrell, 3d Amer. ed., 1881, vol. ii. p. 17. 
* Tyrrell, Med.-Chir. Rev., vol. x. p. 601. 

5 Barton, Goodman's ed. of Sir A. Cooper on Disloc., etc., p. 121. 
,; Malgaigne, Amer. ed., p. 341. 

7 Chelius's Surgery, Amer. ed., vol. i. p. B90. A!-. Velpeau'a <>,,. Surgery, 1st 
Amer. ed.,vol. ii. p. 737. 
■ Rogers, Amer. Journ. Bled. Sci., May, L886. 

Velpeau's Surgery, Blackman's ed., vol. ii. p. 892. 
•" Smith, New York Journ. Med., L869, j 

11 Hutchison, Trans. X. V. Med. See., L861, p. 98. 

12 Blair, Ballingall- Military Surg., 6th Edinburgh ed., p. 821. 

\'l 



[78 FRACTURES OF THE VERTEBRA. 

fourth day. In the second case the doctor removed the spinous pro- 
cesses of the fifth and sixth cervical vertebrae, and the entire posterior 
arch of the fifth. The Bheath was not broken, "but the cord was much 
injured." There was almost complete paralysis of the extremities, and 
this condition was not remedied by the operation. Three years later, 
the patient being Mill alive, but only a very slight improvement having 
taken place, I>r. Totter "removed the fourth, sixth, and seventh cervical 
vertebrae." (We presume he intends to say the "posterior arches.") At 
the time of the report. January, 1S63, there was no further improve- 
ment. Finally the doctor reports a completely successful case. The 
injury \\a< of "five months' standing." 1 Packard says, in a note to his 
translation of Malgaigne, that Dr. Potter operated on a case of three 
month-' standing, and the patient died on the eighteenth day. I suppose 
this to be the same case. Lucke operated on the eleventh dorsal verte- 
bra, and the patient died three months later. 

In 1867 M. Denuce, of Bordeaux, operated, the day following the acci- 
dent, upon a man aged twenty-four years, who had a fracture of the last 
dorsal arch. The arches of the last dorsal and first lumbar were elevated. 
The spinal marrow did not appear to be contused, although he had com- 
plete paralysis of the lower extremities. The man died two days later. 2 

These are all of the cases of which the author has any information in 
which this operation had been made, and they have all, excepting the 
two caves reported by Potter and the one by Blair, terminated fatally in 
a very Bhort time. The case reported by Alban G. Smith, of Kentucky, 
i- not related in such a manner as to enable us to make use of it safely, 
nor i- it stated how long the patient survived the operation; Gibson says 
it gave no permanent relief. The example mentioned by an English 
writer is equally unreliable, inasmuch as it is o'iven only upon rumor, and 
hut a ••few months" had elapsed since the operation was performed. It 
was -aid to have been made in the year 1838, by a surgeon of the name 
of Edwards, in South Wales: and it was affirmed that the compression 
was relieved and that the patient "did well." 3 So unique a case would 
certainly have found before this an ample confirmation. Indeed, I must 
Bay that none of the cases reported as successful give any eAddence of 
authenticity. 

Experience, then. Beeme to have shown that we have little or nothing 
to expect from this surgical expedient; and, notwithstanding the strong 
hope expressed by Sir Astley Cooper that Mr. Cline's operation might 
hereafter proves valuable resource, and contrary to the conclusions which 
I in common with many other surgeons had drawn from the anatomical 
relation- of these parts, I am compelled reluctantly to declare that the 
expedient i- scarcely worthy of a trial. To the same conclusion, also, 
many of the mosl distinguished surgeons have arrived, among whom we 
may mention, a- especially entitled to confidence, Brodie, Liston, Alex- 
ander Shaw. Malgaigne, and Gibson. 

" Chedevergne, after analyzing the previous papers of MacDonnel and 
of Pelizet, has collected 25 cases of trephining of the spine, which give 

r. Med. Times, Jan. LO, 1863. 
Lucke, Denuc6, French ed. of this treatise, p. 167. Poinsot. 
Edwanfe, British and Foreign Med. Rev., 1838, p. 162. 



FRACTURES OF THE BODIES OF THE VERTEBR/K. 179 

the following results : 12 operations performed in the dorso-lumbar region 
show 10 deaths. 1 cure, and 1 imknowD result; out of 1-3 operations 
performed in the cervical region, there were 9 deaths and 4 recoveries; 
making a total of 25 operations, with 11' deaths ami ."> recoveries. This 
ratio of successful cases, as Chedevergne says, might possibly he smaller 
than that furnished when the cases are left to themselves." 1 

What more can be said of the attempt to raise the depressed hone by 
seizing the spinous process with the fingers, or with a pair of strong- 
hooked forceps passed through the skin, or finally, if this cannot he 
done, by laving bare both sides of the process and seizing upon it with 
a pair of firm tenacula? This is the alternative presented to Malgaigne, 
and which he ventures to recommend as deserving a trial. In the ab- 
sence, however, of any testimony in its favor, beyond the mere rational 
argument adduced by this distinguished writer, we must waive any 
further consideration of the subject; only expressing our conviction that 
it will be found, after a fair trial, as usele>> and as inexpedient as the 
more severe operations of Cline. 

Jeffries Wyman, of Boston, has met with eleven specimens of old united 
fracture- of the vertebral arches occurring in the fourth or fifth lumbar 
vertebras between the lower articulating and the transverse proc< 
He has also met with the same fracture once in the third lumbar vertebra. 
The frequency of this peculiar form of fracture in this region. Dr. Wyman 
ascribes to the fact that the upper and lower articulating processes are 
widely separated from each other, and connected only by a narrow neck. 
in which respect they contrast very strongly with the dorsal vertebrae; 
and he supposes that the fractures may be caused by either a forcible 
bending of the body backwards, or by the shock resulting from a fall 
from a height in which the force of the concussiou is conveyed downward- 
through the pelvis. In no ease has the existence of this fracture been 
recognized during life, nor is it probable that its occurrence would cause 
any marked svmptoms unless it had been caused by a blow directly from 
behind. 2 

A- to the therapeutical treatment of the various symptoms belonging 
to these accidents, and in relation to the prognosis, the remarks which 
we -hall make will be found equally applicable to fractures of the bodies 
of the vertebrae, and we shall reserve the consideration of* these topics 
for the following Bection. 

> 4. Fractures of the Bodies of the Vertebrae. 

The same causes which produce fractures of* the arches may produce 
also fractures of the bodies of the vertebrae, that i-. blow- received 
directly upon the extremities of the spinous processes; but in these cases 
the arches are generally broken ;it the same time. 

In other cases the bodies of the vertebrae are broken by foils upon the 
top of the head, by which the vertebrae are not only driven forcibly 
together, but often doubled forwards upon each other: or the patient 
may have alighted upon hi- feel or upon bis sacrum. 

i (] Poinsot, •-)>. 

- Wvmai . o -• M nd Surg. J fkuj 



180 FRAOTU R BS OF Til K V ERTEBE M. 

Reveille* has reported a case of fracture of the fifth cervical vertebra 
from muscular action, which occurred in diving. The man was taken 
..in of the water unconscious, and died in a lew hours, having declared 
before death that his head did not strike the bottom, although he had 
jumped from a height of seven or eight feet, and the water was only 
three feet deep. 1 The statement of the sufferer, under such circum- 
stances, could not really possess much value, and we think we see good 
reason to suppose that he was mistaken. South also relates a case of 
fracture of the fourth and fifth cervical vertebrae occasioned by diving, 
in which it was supposed that the fracture was caused by the concussion 
of the head upon the water.' 

Malgaigne says the spine bends at three principal points; comprised, 
the first between the third and seventh cervical vertebrae, the second 
between the eleventh dorsal and second lumbar, the third between the 
fourth Lumbar and the sacrum: and that a majority of the fractures of 
the vertebras occur at these points of flexion. He makes an argument 
from this also that these fractures "are generally the result of counter- 
strokes, as the effect of forcible flexion of the column either forwards or 
backwards.' 1 Malgaigne observes, moreover, that dislocations follow the 
same rule. 

M. Chedevergne thinks that indirect fractures are much more frequent 
than direct, and he makes of these two varieties, namely, those caused by 
tearing and those caused by crushing, the former being the result of 
forced flexion forwards or backwards, the lesion being usually at the 
twelfth dorsal or first lumbar. By experiment on the cadaver, M. Che- 
devergne has determined that in flexion forwards the apophysis of the 
twelfth dorsal vertebra is broken off, the great superspinous ligament 
torn, and finally the body of the vertebra is separated into two parts, of 
which the superior is the smallest. In flexion backwards the primary 
lesion takes place in front." 

The direction of the line of fracture varies greatly in the different 
examples which we have seen : some are crushed, and more or less com- 
minute!. In some cases a narrow piece is chipped from the margin, 
others are broken transversely, and others obliquely. In oblique frac- 
turee the line of the fracture is generally from behind forwards, and from 
above downwards. Malgaigne thinks that a crushing or comminution 
'•an only occur from a forcible flexion forwards; but I have seen at least 
'.no example in which this was not the fact; the patient having fallen so 
as to strike with the back of his neck upon an iron bar. This was the 
of the sailor, to which I shall again refer more particularly. 

The upper fragment is almost always that which suffers displacement; 
sometimes being simply driven downwards, and thus made to penetrate 
more or [ess the lower fragment ; at other times, as in certain transverse 
fractures, it is only displaced forwards, and in still other examples, where 
the fracture i- oblique, the upper fragment is displaced both downwards 
and forwards. 

ill. -ii. Cheliue'a Surg., note by South, vol. i. p. 584. 
.tli. ibid., ]■ 
Ch6dei M in. de I'Acad. de Med., Paris, 1869-70, torn. 29, p. 73. 



FRACTURES OF THE BODIES OF THE VKETEBR.K. 



181 



Fig. 41. 




Oblique fracture of the body 
of a vertebra. 



In the first and last of these examples the spine becomes bent forwards 
at the point of fracture, producing an angle of which the most salient 
point posteriorly is represented by the extremity of the spinous process 

belonging to the broken vertebra : in the second 
example the spinous process of the broken verte- 
bra is depressed, and the process of the vertebra 
next below is relatively prominent. 

In a pretty large proportion of cases also the 
fracture of the body of the vertebra is compli- 
cated, as we have already stated, with a fracture 
<»f the arches, in some instances with a fracture 
of the oblique processes, and with a dislocation. 

Symptoms. — Severe pain at the seat of frac- 
ture, felt especially when the part is touched or 
the body is moved, tenderness, swelling, ecchy- 
niosis. occasionally crepitus, a slight angular 
distortion of the spine, or simply a trifling ir- 
regularity in the position of the processes, and 
paralysis of all the parts whose nerves take their 
origin below the fracture, are the usual sign- of 
the accident. 

The paralysis may be due to the mere pressure of the displaced frag- 
ments, but it \.- much more often due to a severe and Irreparable lesion 
of the cord itself. I have, in one instance, seen the cord almost com- 
pletely separated at the point of fracture, although the displacement of 
the fragments was inconsiderable. 

Accompanying the paralysis of the bladder, there has been generally 
observed an alkaline state of the urine, and subacute inflammation of 
the coats of the bladder. Priapism is present in a certain proportion of 

Those who die immediately seem to be asphyxiated : while those who 
die later wear out from general irritation, tins condition being frequently 
accompanied with an obstinate diarrhoea and vomiting. A few become 
comatose before death. 

It will be seen, moreover, that a certain proportion finally recover; 
but scarcely ever are all the functions of the limbs and of the body com- 
pletely restored. 

We shall render this pari of our description of these accident- more 
intelligible if we regard them as they occur in the various portions of the 
spinal column, since the Bymptoms, prognosis, and treatment have refer- 
ence mainly to the point at which the fracture has occurred. 

1. Fracture* of tin' /!>></;,.■< of the Lumbar Vertebrce. 

The spinal cord terminates, in the adult, ;it the lower border of the 
first lumbar vertebra, hut in the child ;«r birtb it extends ;■- low =i- the 
third lumbar vertebra. The remainder of the vertebral canal is occupied 
by the leash of terminal nerves, called collectively the cauda equina. 

' The nerve- which emerge from the intervertebral foramina belo* the 
fourth and fifth lumbar vertebrae, unite with the sacral nerves to form a 



L82 



FRACTURES OF THE VERTEBRA. 



plexus which supplies the sphincter and levator ani, the perineal muscles, 
the detrusor and accelerator, urinae, the urethra, the glans penis, and a 
mat proportion of the lower extremities. It will be apparent, there- 
t'oiv. that ;i fracture, with displacement, of even the last vertebra of the 
column, involves the possibility of more or less paralysis of all those 
parts supplied by this plexus, and that in proportion as the fracture is 
higher in the vertebra] column, will the probability of additional compli- 
cations be increased. In other words, in addition to the more or less 
complete loss of function in the organs supplied by the ilio-sacral plexus, 
there will probably be associated loss of function in other organs, sup- 
plied from sources above this point of the vertebral canal. 

A fracture, however, of the bodies of the fourth or fifth lumbar verte- 
bra, produced by a direct blow, is exceedingly rare, owing to the protec- 
tion which it receives from the alae of the pelvis. 

Dr. Alexander Shaw lias reported four cases of fracture below the 
second lumbar vertebra, which were unaccompanied with any degree of 
paralysis, and which were followed by speedy recovery, 1 a circumstance 
which be ascribe- to the fact that the cauda equina is composed of nerves 






Fig. 12. 



considerable firmness, and suspended loosely together; for 
this reason they escape pressure by slipping 
among themselves, and suffer less injury from 
the same amount of compression than the medulla 
spinalis. 

In the two following cases the results were 
less fortunate, yet recoveries seem to have taken 
place. 

A boy was admitted into St. George's Hos- 
pital, in September, 1827, with a fracture and 
(considerable displacement of the third and fourth 
:/\wew lumbar vertebrae, the displacement being suffi- 
cient to cause a manifest alteration in the figure 
of his spine. His lower limbs were paralyzed. 
An attempt was made to restore the displaced 
vertebrae, but it was attended with only partial 
success. At the end of a month he had slight 
involuntary motions of the lower extremities, and 
at the same time he began to recover the power 
of* using them voluntarily. Three or four months 
after the receipt of the injury be left the hospital, and the history of his 
case was interrupted at this date.-' 

Dr. Thompson, of Goshen, X. Y., reports also a fracture of either the 
third or fourth lumbar vertebra, followed by recovery. The patient fell 
from the roof of a house, Btriking first upon his feet and then upon his 
buttocks. This occurred in October, 1853. The usual signs of a frac- 
ture were present, such as paralysis, etc. A bedsore formed above the 
top of the sacrum, and a piece of bone exfoliated, which seemed to belong 
to the lasl lumbar vertebra. Ho was confined to his bed seven months. 




• aotare of the 
Brat lumbar vertebra. 



London Med. Gaz., vol. xvii. 

.\-t. Cooper on Disloc, <<]>. cit., p. 471. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 183 

After eighteen months he began to use crutches. At the end of about 
three years all improvement ceased, at which time he could not quite 
stand alone: yet. with the aid of apparatus, lie was aide to get about the 
country and vend books, prints, etc. This was also his condition one 
year later. 1 

A patient in Guv's Hospital, under Mr. Key. with a fracture of the 
first lumbar vertebra, lived one year and two days. On examination 
after death, it was ascertained that bony union had occurred between the 
fragments, and that the spinal marrow was completely separated at the 
point of fracture. 2 

Mr. Harrold relates a case of fracture of the first and second lumbar 
vertebrae, in which the patient survived the accident one year, lacking 
nine days; death having resulted finally from a sore on the tuberosity 
of the ischium and disease of the bone. After death it was ascertained 
that the fracture had united by bone, and that the spinal marrow was 
almost completely cut in two, the divided extremities being enlarged and 
separated nearly an inch from each other. 3 

2. Fractures of the Bodies of the Dorsal Vertebrce. 

In these examples the same organs are paralyzed as in the fractures 
lower down, in addition to which there is generally considerable disturb- 
ance of the functions of respiration, irregular action of the heart, indi- 
gestion, accompanied with a tympanitic state of the bowels. 

Dupuytren, who reports several examples of fractures of the dorsal 
vertebrae, has not taken the pains to record the length of time they 
survived the accident except in two instances, both of which were frac- 
tures of the eleventh vertebra. One died of suffocation on the tenth 
day. and the other on the thirty-second. In Sir Astley Cooper's cases, 
mention is made of a fracture of the twelfth dorsal vertebra, which the 
patient survived fifty-two days, one of the tenth dorsal, which terminated 
fatally in six days, and another of the ninth dorsal, which did not result 
in death until after nine weeks. 

In 1853 Dr. Parkman presented to the Boston Society for Medical 
Improvement a specimen of fracture of the fifth dorsal vertebra, the 
bodies of the third and fourth being also displaced forwards, in which 
position they had become firmly ossified. The spinal cord had been 
completely separated, yet the patienl survived tin- accident two months. 1 

Dupuytren has related also two examples of fractures, one of the tenth 
and the other of the lasl dorsal vertebra, from which the patients com- 
pletely recovered after from two to four months' confinement. A similar 
ease is related by Lente, of New York. Barney McGuire, having fallen 
a distance of twelve or fifteen feel upon hi- back, was found with Dearly 
complete paralysis of hi- Lower extremities and of his bladder. Swelling 
existed over the lower dorsal vertebrae, and this point was very tender. 

1 Thompson, Amer. Journ. Med, Sri.. Oct. is:,;. Lente'fl p 

2 Key, A. Cooper on I > it., p. W7. 

3 Harrold. A. Cooper, op. cil •• I 

* Parkman, Now York Join- Id tfarch, 1868, p. 
5 Dupuytn pp. 866 7. 



]s \ FRACTC H BS ov Til K VBRTEBB .!'.. 

luently, when the Bwelling Bubsided, the prominence of the Bpinoue 
processes of the tenth and eleventh dorsal vertebrae put the question of 
b fracture beyond doubt. Gradually, under the use of cups, strychnia, 
mineral acids, laxatives, buchu, and electricity, his. symptoms improved. 
In >i\ months be was able to walk aboul the Btreets, and four years after 
the accident he was employed in a foundry under regular wages, being 
able to stand fifteen or twenty minutes at a time, and to walk half a mile 
without resting. At this time there remained do tenderness in the spine, 
but the projection of the process was the same as at first. 1 

3. Fractures of the Bodies of the five lower Cervical Vertebrae. 

\\ e shall now have added to the Bymptoms already enumerated, 
paralysis of the upper extremities, greater embarrassment of the respira- 
tion with diminished action of the heart, and more complete loss of 
sensation and volition in the lower part of the body. In general, also, 
the eyes and face look congested, owing to the imperfect arterialization 
of the blood, and death is more speedy and inevitable than in examples 
of fracture occurring lower down. 

In ten recorded examples of fractures of the five lower cervical ver- 
tebrae which I have been able to collect, one died within twenty-four 
hours, four in about forty-eight hours, one in eleven days, and one lived 
fifteen week- and six days, one about four months, one fifteen months, 
and one, reported by Hilton, survived fourteen years.- The most com- 
mon period of death Beems, therefore, to be about forty-eight hours after 
the receipt of the injury. 

The example of the patient who survived the accident fifteen weeks 
and Bis day-, is recorded by Mr. Grreenwood, of England. A woman, 
Mary Vincent, aet. 47. was injured by a blow on the back of her neck, 
but Bhe was oot -ecu by Mr. Greenwood until after eleven days, at which 
time she was breathing with difficulty, occasioned by paralysis of the 
intercostal muscles, respiration being carried on by the diaphragm and 
abdominal muscles alone. This was the extent of the paralysis. There 
seemed to be a depression opposite the fourth and fifth cervical vertebrae, 
and pressure al this point occasioned universal paralysis, as did also the 
action of coughing and gneezing. About three weeks after the accident, 
she attempted for the first time to move in order to have her clothes 
changed, when Bhe was immediately seized with paralysis in the right 
arm and hand. After this Bhe lost her appetite, had frequent attacks of 
purging, and thus she gradually wore out. 8 

The patient who survived about four months was admitted into Hotel 
Dieu, under the care of Dupuytren, in L825, on account of a fracture of 
the fourth cervical vertebra, caused by a fall on the back of his neck, and 
suffering from paralysis of the bladder and extremities. After two 
month- and a half of entire rest, he was convalescent, and quitted the 
hospital, with only slight weakness in his left leg, and with his head a 

l. \m.T. Journ. Med, Bci., Oct. 1857, p. 361. 

Hilton, Lond. Lancet, Oct. 27, I860. 

\ . < looper "ii Disloc . p. 172. 



FRACTURES OF THE BODIES OF THE VERTERRJ-:. 185 

little bowed forwards. In returning from a Long walk he fell paralyzed, 
and remained in the open air all night. From this time he continued to 
fail, and died thirty-four days after the second fall. On examination 
after death, the body of the vertebra was found to be broken, and also the 
processes of the fifth, allowing the fourth to slip forwards and compress 
the cord. A true callus existed in front of these bones, winch looked as 
if recently broken. The cord itself exhibited an annular constriction, 
which Dupuytren conceived to he the seat of the original lesion narrowed 
by cicatrization. 1 

The following example furnishes a fair illustration of the usual phe- 
nomena which accompany fractures of the third or fourth cervical ver- 
tebra. 

On the 25th of July, 1857. a sailor fell backwards from the wharf, 
striking with the nape of his neck upon a bar of iron. I saw him on 
the following day. in consultation with his attending physician, Dr. 
Edwards. He was lying upon his back, breathing rapidly. His lower 
extremities were completely paralyzed; legs and feet swollen and purple; 
right arm completely paralyzed, and his left partially: from a point 
below the line of -the second rib, there was no sensation whatever: his 
bowels had nol moved, although he had already taken active cathartics: 
the urine had been drawn with a catheter: the pulse was slower than 
natural, and irregular. He was constantly vomiting. In reply to ques- 
tions, he said that he felt well, articulating distinctly, and with a good 
voice. His eyes and face were somewhat congested, but with this excep- 
tion his countenance did not betray the least physical disturbance. He 
lived in this condition about forty hours, only breathing shorter and 
shorter, and his consciousness remaining to the last moment. 

In proceeding to examine the spine a few hours after death, and before 
any incision was made, we were unable, upon the most minute examina- 
tion, to detect any irregularity of the processes of the cervical vertebras, 
or any crepitus; but. on dissecting the neck, we found that the arches of 
the third and fourth vertebrae were broken, and the spinous processes 
slightly depressed upon the cord. The bodies of the corresponding 
vertebra 1 were comminuted, and the vertebra 1 above were driven down 
upon them, carrying the processes in the Bame direction. The theca and 
the spinal marrow were almost completely severed upon ;i level with the 
fourth vertebra. 

A man residing in Erie ( '".. N. Y.. was thrown backwards suddenly 
from tlu- back end of n wagon, alighting upon the top of his head. Dr. 
Mixer having requested me to see tlii- patient with him. I found the 

symptoms almosl an exaci counterpart of those which belonged to the 
ease which I have jusl described, excepl thai ;> crepitus and a mobility 

of the fragments could be distinctly felt in the upper and back part of 

his neck. Hi- death occurred in very much the Bame manner after 
about forty-eighl hours. No autopsy \\;i- allowed. We ooticed in this 
case, also, that whenever lie was turned over upon his face, respiration 

almost entirely ceased, but it was immediately restored by laying him 

1 Dupuytren, '>j>. 'it.. ) 



[86 FRACTURES OF THE VERTEBRAE. 

again on his back. Many other similar examples have from time to time 
come under my notice. 

Strains of the Ligaments and Muscles. — Dupuytren, Sir Astley 
Cooper, South, and other surgeons have related cases simulating fracture, 
but which proved to be strains of the ligaments uniting the cervical 
vertebra, accompanied with more or less injury to the spinal marrow. 
In one instance. 1 have met with what has seemed to be a strain of the 
ligaments and muscles of the neck, but which presented no symptoms of 
serious injury to the spinal marrow. 

John Neuman, of Canada West, set. 25, fell headforemost from a 
height of fourteen feet, striking upon the top of his head. He was taken 
up insensible, and remained in this condition six hours. When concious- 
aess returned, his head was very much drawn backwards, and it was im- 
possihle to move it from this position. There was no lack of sensibility or 
of the power of motion in his limbs, and all the functions of his body 
were in their natural state; but he has suffered with occasional severe 
pains in his arms ever since. The accident happened on the twenty- 
fourth ot November, 1857, and he called upon me eight months after. 
Hi- head was then forcibly bent forwards instead of backwards, into 
which position it had gradually changed. In the morning he generally 
was able to erect his head completely, but after a few hours it was con- 
stantly drawn forwards, as when I saw him. There was no tenderness or 
irregularity over the cervical vertebrae, and he was so well as to be regu- 
larly employed as a day-laborer. 

Concussion. — Sir Astley Cooper has collected four examples of what 
he terms ••concussion of the spinal marrow," all of which recovered after 
periods ranging from a few weeks to many months; but in only one case 
i- it Btated that the recovery was complete. 1 Boyer also enumerates three 
cases of concussion which came under his own observation, all of which 
terminated fatally in a short time. In the first example mentioned by 
Boyer, the autopsy disclosed neither lesion nor effusion of any kind; in the 
second case, it does not appear that any autopsy was made. The third is 
related as follows: "A builder fell from a height of fourteen feet, and 
remained for some time senseless; and, on recovering from that situation, 
found that lie had lost the use of his inferior extremities. He had at the 
same time ;i retention of urine, an involuntary discharge of the feces, and 
some disorder in the function of respiration. Death followed on the 
twelfth day nftcr the accident. The body was opened, and the vertebral 
canal was found to contain a sanguineous serum, the quantity of which 
was sufficient to fill a little more than its lower half." 2 No doubt some 
of the cases reported as concussion were only examples of paralysis from 
ivasation of blood, a circumstance which is peculiarly likely to happen 
as ;i result of the rupture of one of those numerous large vessels which 
surround the vertebrae outside of the thecse. It is seldom that the vessels of 
the cord itself give out sufficient blood in these cases to cause compression. 
Possibly examples of compression as a result of extravasation of blood 
may sometimes be recognized by the fact of the gradual approach of the 
paralysis after the lapse of several hours, as has occurred recently in a 

i toper, ")>. '-it., p. r. t. 
. Lecture on Diseases of the Bones, Arner. ed., 1805, p. 55. 



FRACTURES OF THE BODIES OF THE VERTEBRA. 187 

case brought to my notice at the Bellevue Hospital, and in which recovery 
finally took place. 

4. Treatment of Fraetures of the Bodies of the Vertehrce when the frac- 
ture occurs in any portion of the column belotv the Second Cervical. 

In a few instances, I have noticed among the recorded examples of 
fractures of the bodies of the vertebrae, that surgeons have made some 
slight attempt to reduce the fracture, or rather to rectify the spinal dis- 
tortion, generally by the application of moderate extension to the limbs, 
and by laving the patient horizontally upon a hard mattress. But I have 
not been able to discover that in any case the patients have derived 
benefit from the attempt, although it has been said occasionally, by the 
gentleman making the report, that the deformity was slightly diminished. 
Nor am I aware that in any instance the patient has suffered any damage 
from the attempt: at least the reporter has in no case thought it necessary 
to make this observation. I am confident, however, that such manipulation 
can seldom serve any useful purpose, and I very much fear that it has 
been frequently a source of mischief; although in cases so generally fatal, 
it might be very difficult to estimate with much accuracy the amount of 
injury done. If by any possibility the fragments could be replaced, I 
know of no means by which they could be kept in place; and in truth 
we are much more likely to increase the penetration of the spinal cord 
and the general disturbance, than to diminish it, by extension or pressure. 
Moreover, it usually inflicts upon the unfortunate sufferer great pain, and 
for these reasons it ought generally to be discouraged. 

I have, however, met with two cases of fracture of the lumbar vertebrae, 
in which relief was afforded by permanent extension When the fracture 
is below the middle of the vertebral column, extension, if employed, 
should be made by adhesive straps, weights, and a pulley, as will hereafter 
be directed in fractures of the femur; the counter-extension being made by 
the weight of the body. It will be understood, however, thai when 
paralvsis exists the ligation of a limb with bandages will expose the 
patient to great danger of ulceration and sloughing at and below the points 
of pressure, and the amount of extension must lie very moderate. 

When treating of fraetures of the arches of die vertebrae, I took occa- 
sion to call attention to Mr. Cline's operation, occasionally recommended 
and practised in such cases. I was nol ignorant, however, thai Mr. ('line, 
and several other of the advocates of tins operation, had recommended ii 
especially for fractures of the bodies of the vertebrae when accompanied 
with displacement. Even Malgaigne has preferred to consider the merits 
of tin- operation in its relations to these latter fractures; bul whilst I am 
prepared to admit the propriety of an argumenl as to the value of Cline's 
operation considered in reference to fractures of the arches, I cannot admil 
its propriety in reference to fractures of the bodies of the vertebrae. 
The proposition appears to me too absurd to be entertained for a moment. 

The treatment, then, ought t<» !»<■. in n great measure, expectant. The 
patient should be laid in such a position as lie finds most comfortable, ;• n< L 
as fii- ;i- possible, tin- spine should be kept at rest, since the mosl trivial 
disturbance of the fragments, and even tli«t which may cause no pain to 



188 FRACTURES OF THE VERTEBK.K. 

the patient, is liable to increase the injury to the spine, and prevent the 
formation of a bony callus. Especially ought the surgeon to be careful, 
while making the examination, not to turn the patient upon his face, in 
which position the spine loses its support and a fatal pressure may be 
produced. The urine should be drawn very soon after the accident, and 
at least twice daily for the next few weeks. Indeed, it is a better rule 
to draw the urine as often as its accumulation becomes a source of in- 
convenience, or whenever the bladder fills, which will in some cases be 
:i- -»(':, -ii as every four or six hours. It is especially necessary to attend 
t<» those urgenl demands of the patient during the first few weeks, when 
the paralysis is most complete generally, and the mucous surface of the 
hi udder, already irritated and inflamed by the excessively alkaline urine, 
suffers additional injury from any degree of painful distention of its walls. 
It i- unnecessary to say that the frequent introduction of the catheter 
may itself prove a source of irritation, unless it is managed carefully and 
skilfully. This duty ought never to be intrusted. to an inexperienced 
operator. 

[do nol see what advantage the surgeon can expect to derive from the 
administration of drastic purgatives, such as full doses of jalap, castor 
<»il. or spirits of turpentine, at any period. If in the first instance the 
bowels are so completely paralyzed that they seem to demand such 
violent measures to arouse them to action, we may be quite certain that 
the spinal cord is Buffering from a pressure, or from some lesion, which 
these agents have no power to remedy. The bowels may possibly be 
made to act. hut it would be difficult to show how this is to relieve the 
Buffering cord. So far from affording relief, these measures add directly 
to the nervous irritation and prostration, and provoke vomiting and general 
restlessness. It is not desirable, we think, to obtain a movement of the 
bowels, during the first few days by any means, however gentle. The 
effort to defecate, and the consequent motion, will probably do much 
more harm than the evacuation can do good; and especially, for the 
same reason, ought we to avoid putting into the stomach anything which 
w ill occasion nausea and vomiting. 

After the lapse of a few days, if reasonable hopes begin to be enter- 
tained of a recovery, it will become important to establish regular evacu- 
ations of the bowels, either by a judicious management of the diet, by 
.-•■ntle laxatives, or by enemata. At a still later period, when the in- 
flammatory stage is past, and the nerves remain inactive or paralyzed, 
nothing could he more rational than the employment of strychnia in doses 
varying from the one-twelfth to the one-eighth of a grain three times 
daily. Nor do I think that any single remedy has more often proved 
useful in my own practice, or in the practice of other surgeons with 
whom 1 am acquainted. In order, however, to derive benefit from this 
or any other remedy, it must he continued for a long time; perhaps for 
ar or more. Electricity, Betons, issues, and blisters are no doubt 
also -.I,,, .1,,,,,.. useful. I lare musl he taken that setons, etc., do not pro- 
duce bedsores. Passive motion and frictions, good fresh air, and nour- 
ishing diet, become at last. essential to recovery. From an early period, 
and during the whole course of the treatment, great attention should be 
paid to the prevention of beil^ores. by supporting all those parts of the 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 189 

bodv upon which the pressure is considerable. For this purpose we may 
employ circular cushions, air-cushions, and air-beds; hut water-beds are 

very much to he preferred to air-beds as a means of preventing bedsores. 
Water-beds must be filled with water at the temperature of 68° Fahren- 
heit, and they must be secured in position by side boards, or a kind of 
shallow box, the sides of which are elevated six or seven indies. Per- 
manent extension can be employed upon these beds as well as upon ordi- 
nary beds. Sometimes a section i)\' a bed. three feet square, is found 
quite as serviceable as an entire bed. inasmuch as the back and nates 
are the only parts which are liable to bedsores. They may be obtained 
from the manufacturers, Hodgman & Co.. corner of Nassau Street and 
Maiden Lane. New York City, at prices ranging from $15 to $25. Of 
late I have found the wire-beds, manufactured at 59 Pearl Street. Hart- 




ford. Conn., excellent substitutes for water-beds. They are less expen- 
sive, more easily managed, more durable, and admit of a much better 
regulation of the temperature. Whether they are quite as efficient in 
the prevention of bedsores as water-beds, I cannot say positively, but 
they have been much used under my observation at Bellevue and in the 



Fig. 44. 




Bonnet's vertebral gutter. 

Hospital for Ruptured and Cripples, and I have seen no bedsores occur 
where they were in use. In ;< f< w cases it may be found useful t<> sup- 
port the back, including the neck and Dates, with ;i wire cuirass, well 
padded: and especially where the confinement i- greatly prolonged. 

When sores have formed, they should be treated, if sloughing, with 
yeast poultices, or the resin ointment. I find also tin- resin ointmenl an 



[90 i RAOTUH BS OF TH K V E RTBBR M. 

exoellenl dressing for the sores after the sloughs have separated. In 
the Burfaoe is onlj slightly abraded, simple cerate forms the best 
Application. 

I 5. Fractures of the Axis. 

The phrenic nerve is derived chiefly from the third and fourth cervical 
nerves. 11", therefore, the second cervical vertebra is broken, and con- 
siderably depressed upon the spinal cord, respiration censes immediately, 
and the patienl dies al once or survives only a few minutes. In such 
examples of fracture of this bone as have no1 been attended with these 
results, the displacement and consequent compression have been incon- 
siderable, or there has been no displacement at all. 

Mr. Else, of St. Thomas's Hospital, says that ;i woman in the venereal 
ward, and who was then under ;i mercurial course, while sitting in bed, 
eating her dinner, was seen to hill suddenly forwards; and the patients, 
hastening to her, found thai she was dead. Upon examination of her 
body* it was discovered that the processus dentatus of the axis was broken 
..IV. and thai the head in falling forwards had driven the process back- 
wards upon the spinal marrow so as to cause her death. 1 

Sir AmIcv Cooper also relates the case of a man who was shot by a 
pistol through the neck, breaking and driving in upon the spinal marrow 
both the "lamina and the transverse process" of the axis, lie died on 
the fourth daj .' 

Malgaigne has collected three cases of fracture <>f the odontoid apo- 
physis, all of which were accompanied with displacement of the atlas. 
The first, reported by Richet, died on the seventeenth day; the second, 
reported by Palletta, died after one month and six days; and the third, 
lived four months and two weeks. Swan has reported ;i case, 
also, of fracture accompanied with dislocation of the head upon the atlas, 
in w hich death ensued immediately. 3 

Rokitansk) Bays that there is ;i specimen contained in the Vienna 
Museum, taken from ;i patient who survived the accident some time, 
although the fragments never united. 

M. Denuce, of Bordeaux, has seen a case of incomplete fracture of this 
process, caused by a gunshot, the hall having lodged in the body of the 
bone. The patienl survived four weeks.' 

Tli.' following case is reported by Parker: 

"The patient, Mr. <>. a. Spencer, was a mini forty years of age, a 

milkman h\ occupation, of medium height, nervo-sanguine temperament, 

of active business habits, and capable of great endurance. His life was 

' constant excitement, and ho was addicted f<» the free use of liquors. 

Mr suffered, however, from no other form of disease than occasional 

attacks of rheumatism, for which ho was accustomed to take remedies of 
bis own prescribing, which were generally mercurials, followed by liberal 
of iodide of potassium, -to work it nil out of the system.' 

\ I ooper "ii Del..,., etc., op. cit., p. 462. 
\ l »per on Disloc, etc , op. cil , p. 176 

•" Med and Surg. Journ., is;:. v ..l. i. p. 226. 
1 Denuce, Nouv. Die. de Ifed. el de Ohir. Prat., t. iii. p. 810. 



FRACTURES OF THE AXIS. 191 

"On the 12th of August. 1852, while driving a 'fast horse' at the 
top of his speed on the plank road near Bushwick, L. I., he was thrown 
violently from his carriage by the wheel striking against the toll-gate. 

He alighted upon his head and faee about fifteen feet from his carriage. 
Upon rising to his feet he declared himself uninjured, hut soon after 
eomplained of feeling faint: after drinking a glass of brandy he felt 
better, got into his carriage with a friend, and drove home to Rivington 
Street in this city, a distance of more than two miles. There was so 
little apparent danger in this ease that no physician was called that 
night. Early on the morning of the following day. Dr. 13. was called 
to visit him. He found his patient reclining in his chair, in a restless 
>tate. and learned that he had suffered considerable pain in the hack 
part of his head and neck during the night. He was entirely inca- 
pacitated to rotate the head, which led to the suspicion of some injury to 
the articulations of the upper cervical vertebne: hut so great a degree 
of -welling existed about the neck as to prevent efficient examination. 
There was no paralysis of any portion of the body, his pulse was about 
90, ami hi- general system but little disturbed. Warm fomentations 
were applied to the neck, and a mild cathartic administered. On the 
following day there was no particular change in his symptoms, but as 
there existed considerable nervous irritability, tinct. hyoscyami was pre- 
scribed as an anodyne, and fomentations of hops applied locally. On 
the third day leeches were applied to the neck, and after this the swell- 
ing so much subsided that on the fifth day an irregularity was discovered 
to exist in the region of the axis and atlas, which had many of the 
feature- of a partial luxation of these vertebrae. 

••At this time he began to walk about the room, having previously 
remained quiet on account of the pain he suffered on moving. He per- 
sisted in helping himself, and almost constantly supported hi- head with 
one hand applied to the occiput. He often remarked, if he could be 
relieved of the pain in his head and neck, lie should feel well. He 
began to relish hi- food, and the swelling nearly disappeared at the end 
of a week, leaving a protuberance just below the base of the occiput, to 
the left of the central line of the spinal column, with a cone-ponding 
indentation. Notwithstanding -trier orders to remain quietly at home. 
on the ninth day after the accident he rode our. and in a day or two 
after returned a- actively a- ever to his former occupation of distributing 
milk throughout the city to his old customers. During the following 
four month- no material change took place in hi- symptoms, although lie 
constantly complained of pain in hi- head. For this period he did not 
omit a single day hi- round of duties as a milkman, which occupied him 
constantly and actively from five o'clock in the morning to nearly noon. 
On the first of November. Prof. Watts examined him. and inclined to 
the opinion that there was a luxation of tie- upper cervical vertebrae. 

"About the 1-r of January, 1853, tie- pains, from which he had been 
a constant Bufferer, became more severe, and he was hoard to complain 
that he could not live in hi- present condition; he remarked, also, that 
he had heard a snapping in hi- Deck. After going his daily round on 
the 11th of January, he complained of feeling cold, and afterwards of 
numbnes- in hi- limb-. In tie- evening he had a chill, and complained 



L92 



FRACTURES OV THE VEUTEHRJ. 



of a pain in his bowels. Be passed a restless night, and arose on the 
following morning about -i\ o'clock; he was obliged to have assistance 
in dressing himself, and experienced a numbness of his left, and after- 
wards of his righl side. He attempted to walk, but could not without 
help, and it was observed thai he dragged li is feet. He sat down in a 
.•hair and almost instantly expired, at eight o'clock, a.m., on the 12th of 
January, precisely five months from the receipt of the injury. 

"The autopsy was made thirty hours after death, by Dr. C. E. 
Isaacs, in presence of several medical gentlemen. Muscular development 
uncommonly fine. An unusual prominence discovered in the region of 
the axis and atlas. On making an incision from the occiput along the 
spines of the cervical vertebrae, the parts were found to be very vascular. 
These vertebra were removed en masse, and a careful examination insti- 
tuted. The transverse, the odontoid (ligamenta moderatoria), as also all 
the ligaments of this region, excepting the occipito-axoideum, were in a 
state of perfect integrity; this latter was partially destroyed. A con- 
Biderable amount of coagulated blood was found effused between the 
fractured surfaces, some of it apparently recent, but much of it was 
thought to have occurred at the time of the accident, and afterwards to 
have prevented the union of the bones. The spinal cord exhibited no 
appearances of any lesion. The odontoid process 
[ '' u -- 4 ~>- was found in the position well represented in the 

accompanying illustration, completely fractured 
off, and its lower extremity inclining backwards 
toward the cord. Death finally took place, 
doubtless, from the displacement of the process 
during some unfortunate movement of the head, 
by which pressure was made upon the cord. The 
destruction of the occipito-axoid ligament, which 
would otherwise have protected the contents of 
the spinal cavity, must have favored this result." 1 
Vander Poel, of New York, has reported the 
case of a man get. twenty-one, who had fallen 
from a carriage upon the back of his head. The 
Bymptoms which ensued led his surgeons to be- 
lieve that he had experienced a fracture of the 
fourth cervical vertebra. His condition subse- 
quently improved to such a degree that he was 
able to perform light labor; but after six months 
they became aggravated, and he died six months and a half after the 
accident, of apneea. The autopsy revealed a transverse fracture of the 
odontoid process, the transverse ligament being uninjured. There was 
in. other fracture of the vertebrae. 2 

Dr. Philip Bevan presented to the Surgical Society of Ireland, in 
L862, a specimen obtained from the dead-room, and which was supposed 
to be an epiphyseal separation of the odontoid process, occurring in early 
life. The history of the case ie not known, although the woman was 

1 Bigelow, N«\\ York Journ. Med., March, 1853, p. 164. 
'-' Vander Poel, Arch. Clin. Surg., vol. ii. p. no. 




lure of the odontoid 
of the ;i\i--. Par- 
lase. ". Broken Bar- 
bae. /;. Odontoid process. 



FRACTURES OF THE ATLAS. 193 

fortv years old when she died. It does not appear very clear to us 
whether this was really an epiphyseal separation, or the result of some 
morbid process. 1 

At the meeting of the New York Pathological Society, Nov. 12. 1868, 
Dr. Austin Flint presented a case of separation of the odontoid process 
of the axis. 

Dr. W. Bayard, of St. John, N. B., has. however, reported a case of 
separation of the odontoid process in a child, followed by complete re- 
covery. In August. 18(34, Charlotte Magee, of St. John, set. (3 years, 
previously in excellent health, fell five feet, striking on her head and 
neck, causing an immediate immobility of the head, which continued 
about two years and a half, when an abscess formed in the back of the 
pharynx, and the bone was spontaneously discharged. Since then she 
has been able to move the head freely, and her recovery may be said to 
be complete. 2 The specimen was subsequently presented to the New 
York Pathological Society, and no doubt remains that the entire process 
was thrown off. 

Dr. Stephen Smith, who has written a very instructive paper on this 
subject, has collected 23 cases of separation of the odontoid process, at 
least 20 of which must be regarded as fractures. The ages of the 
patients range from three years to sixty-eight. Eight of this number 
were spontaneous, the separation being apparently due to some progres- 
sive disease or atrophy of the bone. Two of these recovered after the 
formation of abscesses in the pharynx and the extrusion of the bone. 
In four cases the fractures were gunshot, and one died. The remainder, 
so far as ascertained, were in consequence of blows upon the head : and 
of these only the girl Charlotte Magee recovered. Of the whole num- 
ber. 23. three were without history, two of them being dissecting-room 
cases. 3 

Symptoms. — These will depend much upon the cause and complica- 
tions of the accident. In all cases there will be more or less inability 
to support the head in the erect posture, and if displacement exists, or 
if the products of inflammation press upon the cord, a proportionate im- 
pairment of its functions must ensue. 

Treatment. — The treatment consists in absolute quietude, with mode- 
rate extension, effected by means of suitable apparatus. 

s 6. Fractures of the Atlas. 

I have been able to find only one example of a fracture of the atlas 
alone, and this i- the case related by Sir Astley Cooper ;i- having come 
under the observation of Mr. Cline. 

A boy. about three years old, injured his neck in a severe fall ; in 
consequence of which he was obliged to walk carefully upright, as per- 
sons do when carrying a weight on the head : and when he wished to 
examine any object beneath him, he supported his chin upon his hand, 

1 Sevan, Amer. Journ. Mod. Sri.. April, 1864. From Dublin Med. Prew, Feb. 

18, 1863. 

2 Bavard, Canada Mod. Journ . Dec. 1869. 

3 Smith. Amer. Journ. Med. 8ei., Oct 1871, p 

18 



l!M FRACTURES OF THE VERTEBRJ. 

and gradually lowered bis head, to enable him to direct his eyes down- 
wards. In the Bame manner, also, he supported Ids head from behind 
in looking upwards. Whenever he was suddenly shaken or jarred, the 
shock caused great pain, and he was obliged to support his chin with his 
hands, or to reel his elbows upon a table, and thus support his head. 
The boy lived in this condition about one year, and after death Mr. Cline 
made a dissection, and ascertained that the atlas was broken in such a 
manner that the odontoid process of the axis had lost its support, and 
n;h constantly liable to fall back upon the spinal marrow. 1 



§ 7. Fractures of the first two Cervical Vertebrae (Atlas and Axis) at 
the same time. 

A woman, set. 68, fell down a flight of steps, striking upon her fore- 
head, and died immediately. Upon making a dissection, it was found 
that the atlas was broken upon both sides near the transverse processes, 
and the odontoid process of the axis was broken at its base. These frac- 
ture- wore accompanied with a rupture of the atloi do-odontoid ligaments, 
and a dislocation of the atlas backwards. 2 

South says there is a specimen in the museum of St. Thomas's Hos- 
pital, showing this double fracture. The man had received his injury 
only a few hours before admission to the hospital, and died on the fifth 
day. On examination, the atlas was found to be broken in two places, 
and the odontoid process of the axis at its root. The fifth vertebra was 
also broken through its body. With neither fracture was there sufficient 
displacement to produce pressure, but a small quantity of extravasated 
blood lay in the substance of the spinal marrow, and its tissue was at 
«.ne point broken down and disorganized. 3 

Mr. 1 'lii Hips relates that a man fell from a hay -rick, striking upon the 
occiput : after which, although momentarily stunned, he walked half a 
mile to the parish surgeon, and in two days more he returned to his 
occupation. About four weeks after the accident he was seen by Mr. 
Phillip-, who discovered a small tumor over the second cervical vertebra, 
pressure upon which caused a slight pain. He complained also that his 
neck was -till", and that he was unable to rotate it. No other disturbance 
of the functions of the body could be discovered. After a time the 
tonsils became swollen, and the patient experienced some difficulty in 
deglutition, and. upon examining the throat, a slight projection or fulness 
was discovered ;it the back of the larynx, opposite the second cervical 
vertebra. Subsequently he became affected with general anasarca and 
pleuritic effusions, of which he finally died. Up to the last week of his 
life he was able to walk about his bedroom, and his condition presented 
no Other evidence than has been mentioned, that he was suffering from 
an injury of the spine. He died forty-seven weeks after the receipt of 
the injury. 

The autopsy disclosed a fracture with displacement of the atlas, and 

i Cline, Sir A.8tley Cooper, op. cit , p. 459. 

- Malgaigne, <>]>. cit., torn. ii. p. 383. 

5 Chefiufl'e *ur-n-vy. note by South, vol. i. p. 588. 



FEACTUEES AND DIASTASES OF THE STERNUM. 



195 



a fracture of the odontoid process of the axis. The two vertebrae were 

united to each other firmly by complete bony callus. 1 

Wynperse describes a specimen of gunshot fracture of both bones, in 
which the ball was found imbedded in callus which united the two halves 
of the anterior arch of the atlas. M. Gaucher lias also reported a similar 
gunshot fracture, the subject of which survived 9 months, death "finally 
ensuing upon a secondary displacement of the fragments. 2 



CHAPTER XVII. 



Tursly unite > 
cept in oZdage 



FRACTURES AND DIASTASES OF THE STERNUM. 

Fractures and diastases of the sternum are of rare occurrence, 
owing, probably, to the elasticity of the ribs and their cartilages, upon 
which it mainly rests, and also, in part, to the softness of its structure. 
In advanced life, the ossification and fusion of all of its several portions 
becoming more complete, and the 

cartilages of the ribs also be- Fig. 46. 

coming more or less ossified, a 
true fracture is relatively more 
frequent. 

In some cases no doubt these 
accidents ought to be regarded as 
true luxations, inasmuch as occa- 
sionally the union of the manu- 
brium with the gladiolus is by a 
perfectly formed diarthrodial ar- 
ticulation, as was first demon- 
strated by Maisonneuve in 1842. 
We have, however, in general 
no absolute means of knowing 
whether before the accident the 
several portions which compose 
the sternum were united by bone, 
by a single piece of cartilage, or 
by two distinct cartilages with a 

synovial surface interposed; and inasmuch as the'causes, symptoms, and 
treatment must be essentially the same in either case, it seems unnecessary 
to consider these luxations separately, as Malgaigne, Vidal (de Cassis), 
and others have done. 

Causes. — They are generally the result of direct blows inflicted upon 
the part, such ;i- the passage of ;i Loaded vehicle across the chest, the 

i Phillip,. lfed.-Chir. Trans., vol. x.\. 18;7, p. 

- Wynperse, Gauchet. French ed. ofthia treatise, by Poinsot, \>. 189. 




ZO-2S c h year 
y J soon after puberty 



'//A/4 



v a, rili/ curttiatjL/ious in 
advanced lift 

Sternum, showing the periods at which its sev- 
eral part* unite by bone. (From Gray.) 



l'.u; FRACTURES AND DIASTASES OF THE STERNUM. 

tall of a tree or of Borne heavy timber upon the body; the fracture im- 
plying always that great force has been applied. 

Indirect blows and voluntary muscular action alone have been known 

also occasionally to produce these accidents. 

David, in his M(' moire sur les Contreeoups, published as a prize essay 
by the Academy of Medicine, mentions the case of a mason, who, in 
railing from a -real height, struck upon his back against a cross-bar 
which intercepted his fall, in consequence of which the abdominal and 
Bterno-cleido-mastoidean muscles were so stretched that the sternum 
broke asunder between its upper and middle portions. 1 Sabatier reports 
another case of separation at the same point, produced in a similar 
manner; 9 and Roland has described a third example in a woman sixty- 
three years old, who, falling from a height backwards and striking upon 
her hack, broke the sternum near its centre. 3 Gross and Hodgen have 
recorded similar cases. 4 

Cruveilhier saw a man who, having fallen from a height of twenty feet 
upon his nates, was found to have a fracture of the sternum. 5 Cussan 
-aw the same result in a person who fell from a third story, striking first 
upon his feet and then pitching over upon his back. 6 Maunoury and 
Thoie have reported an analogous case, w T here a man fell from a height 
of twelve or fifteen metres, first striking upon his feet and then falling 
over upon his hack and head. 7 

.Mr. Johnson, late editor of the London Med.-CMr. Hev., reports a 
case a- having been received into St. George's Hospital, in which the 
man, a healthy laborer from the country, had fallen from the top of a 
hay-cart, striking only upon his head. He walked with his head much 
bent forward.-, and was incapable of either flexing, extending, or rotating 
it any farther. The fracture was transverse, and about three inches 
below the toj) of the sternum, opposite the centre of the third rib, the 
lower fragment projecting in front of the upper. The fragments were 
easily replaced by simply throwing the head back, and fell into place 
with an audible snap, but immediately resumed their unnatural position 
when the head was Hexed. They finally united, but with a slight pro- 
jection and overlapping. 8 

Malgaigne expresses a doubt whether all these can be considered as 
the result- of muscular action, since, in a certain number of the exam- 
ple- cited, the head seems to have been thrown forwards by the concus- 
sion, and in others, also, there is no evidence that the muscles attached 
to the sternum were put upon the stretch. The only remaining explana- 
tion is that in such cases the sternum has been broken by the violent 
-hock, or contrecoup. I have myself seen one similar example. In 
December, 1*77. John McLaughlin, aet. 27, was admitted to my service, 

1 Boyer on Diseases of the Bones, flrsl Amor. ed. 1805, p. 57. 
1 Malgaigne, from Sabatier, Mem. but la (Tract, du Sternum. 
1 [bid., 1 1 « .in Bull. deTherap., torn. vi. p. 288. 

' Gross, System of Sure., 5th ed., vol. i. p. 964. Med. Record (N. Y.), Dec. 22, 1877. 
• Malgaigne, from Bull. de la Soc. Anat., Juin, 1826. 
•'■ II- id., from Archiv <\<- M.'<l.. Janv. 1827. 
: Ibid . from Gaz. M«',| . 1842, p. 361. 
London Med.-Chir. Rev., vol. wii.. now -,.,-jo.. p. 536, 1832. 



FRACTURES AND DIASTASES OF THE STERNUM. 197 

Bellevue Hospital, who bad fallen from a height upon his back, causing 
a separation of the manubrium from the gladiolus. There was no sign 
of contusion over the point of separation, but crepitus was distinct. The 

fragments were easily replaced and maintained in position, so that when 
he left the hospital the line of separation could scarcely he felt. 

Dr. Hodgen lias reported to me an example of fracture of the sternum 
caused by a crushing force applied to the hack, and in which, we may 
see plainly, that muscular action was not concerned. A man, seated 
upon a wagon, was driving under a low bridge, with his head very much 
bent down. The bridge caught his back, opposite the shoulders, and 
crushed him forwards, "separating the vertebrae in the dorsal region, 
and breaking the sternum about three inches below its upper end." 
This man recovered. 

Among the most authentic examples of separation of this bone from 
muscular action alone are those in which it occurred during labor. Mal- 
gaigne collected three of these cases, and to these the American trans- 
lator. Dr. Packard, added two more, most of which took place at or near 
the junction of the first and second pieces of the sternum. Dr. Borland 
has added one more "example, which took place at a point near the fourth 
costal cartilage. 1 

Malgaigne relates also the case of a mountebank, who, leaning back to 
lift with his feet and hands a weight, felt suddenly a severe pain in the 
sternal region, and fell over with a fracture of this bone. 

Caseaux, in his Midwifery, says that Chaussier saw two such cases 
occurring in young women in their first labors (both of these are 
included in the cases recorded by Malgaigne); the separation having 
occurred when the head was thrown backwards as far as possible. Compte 
and Martin.' 2 Luchette, and Posta 3 have reported similar examples. 

Mr. Ancelot has reported a case from gymnastic exercise. 4 

The mere act of violent coughing has caused diastasis or fracture of 
the sternum. Mr. Howbridge, referring to the Gazette dcs Hopitaux 
for March, 1830, remarks that the ribs and the sternum have been 
broken in this way; but he adds, that in all probability they arc weakened 
by partial absorption or atrophy. 5 

Lutz reports a case also, of a man aet. 38, the subject of rheumatism 
and asthma, and who had also emphysema of a portion of one lung. 
During a violent fit of coughing he felt something give way on liis chest. 
Severe pain followed, and some swelling. Lutz found the manubrium 
separated from the gladiolus, the former being slightly displaced forwards. 
He was much relieved of his distress by "stretching his neck and throw- 
ing his head backwards." Lutz directed him to make a deep inspiration, 
at the same Time throwing back the head and shoulders. A compress 
was placed over the projection, and secured in place by a broad and firm 

1 J. N. Borland. M.D.. Boston Med. and Surg. Journ., April 20, 1876. 

I assical Diet. Med. and Surgery, xiv. 70. Venice. Quoted by Borland, loc. 'it. 

3 Bulletino delle Scienze Med. <li Bologna, 1857. Quoted h . v Borland, loc cit. 

4 Ancelot, from Lutz. 

II : - System of Surgery, 2d ed., vol. ii. p. 37. 



198 FRACTURES AND DIASTASES OF THE STERNUM. 

band covering the entire chest. Union took place, but with a slight 
overlapping. 1 

Malgaigne says thai Duverney was the first to recognize in certain of 
these accidents a veritable luxation : and Malgaigne further affirms that 

he has collected in all ten cases which should be regarded as luxations. 
According to the plan which I have adopted of disregarding the distinc- 
tion between fractures, diastases, and dislocations of the sternum, for the 
reason chiefly that the exact diagnosis is in general impossible, and never 
of any practical value, these eases referred to by Malgaigne should be 
included in this enumeration of fractures and diastases. 

Boyer believed that the xiphoid cartilage was not susceptible of being 
permanently displaced backwards, except in aged persons, after it had 
become ossified, "for," he says, k< though violently struck and driven 
backwards by a blow on what is vulgarly termed the pit of the stomach, 
yet it restores itself by its own elasticity." 2 

The following case, however, which has come under my own observa- 
tion, is conclusive as to the possibility of this accident: 

A man. twenty-eight years old, fell forwards, striking the lower end 
of bis sternum upon the top of a candlestick, breaking in the xiphoid 
cartilage. During two years following the accident he had frequent 
attacks of vomiting, which were excessively violent and distressing, the 
paroxysms occurring every five or six days. Both Dr. Green, of Albany, 
and Dr. White of Cherry Valley, upon whom he called for relief, recom- 
mended excision of the cartilage, but the patient would not submit to the 
operation. Twelve years after the accident, in the year 1848, while he 
\\a- an inmate of the Buffalo Hospital of the Sisters of Charity, I ex- 
amined his chest, and found the xiphoid cartilage bent at right angles 
with the sternum, pointing directly toward the spine. He now suffered 
no inconvenience from it, except that it hurt him occasionally when he 
coughed. 3 

Polaillon relates the case of a woman ret. 35, who, being pregnant and 
wearing ;i very tight corset, bent herself forwards so as to press the steel 
of the corset upon the xiphoid cartilage. The cartilage was thrown back 
and remained in this position, causing for along time much distress when 
the stomach was disturbed. The surgeons were unable to reduce the 
fracture, hut eventually it ceased to cause inconvenience. 4 

In Martin's case, mentioned by Malgaigne, the accident was followed 
by persistent vomiting: which was finally relieved when the surgeon 
Beized the cartilage with his fingers and restored it to place. In Billard's 
case, referred to also by Malgaigne, the cartilage was restored to its place 
with ;i blunt hook, after having made an incision which penetrated the 
peritonea] cavity. 

The direction of these fractures and diastases is generally transverse, 
or nearly bo; occasionally ;i slight obliquity is found in the direction of 
the thickness of the hone. In three or four examples upon record, the 

i Paper read before the St. Louis Medical Society by F. J. Lutz, A.M., M.D. St. 
u I. and Surg. Journ., July, 1*77. 

B op '-it., p. 69. 

: Buffalo Bled. -I- irn . vol. xii. ,,. 282, Cases of Fractures of the Sternum. 
4 Polaillon. 8oc. '!<• Chir. du Paris, p. !<7. 1876. (.Poinsot.) 



FRACTURES AND DIASTASES OF THE STERNUM. 199 

direction of the separation was longitudinal. It is not so iinfrequent, 
however, to find the bone comminuted. Compound fractures are exceed- 
ingly rare. 

When the line of separation is transverse, the lower fragment is gener- 
ally displaced forwards, and sometimes it slightly overlaps the upper 
fragment: in other cases the direction of the displacement is the reverse. 

I have seen a remarkable case of separation of the manubrium from 
the gladiolus, accompanied with a true fracture and other complications. 

Louis Wilson, set. 60, was. admitted into the Long Island College 
Hospital. April 4, 1866, having just fallen through the hatchway of a 
vessel. He had a compound comminuted fracture of the right leg, a 
fracture of the first four ribs on each side at their necks, a dislocation of 
the sternum from the cartilages of both second ribs, a dislocation of the 
left third cartilage from its rib, a dislocation of the first from the second 
bone of the sternum, and a transverse fracture of the sternum three- 
quarters of an inch below the top of the gladiolus. The dislocation of the 
manubrium was complete, and it was thrust behind the upper end of the 
gladiolus, underlapping it half an inch. The transverse fracture three- 
quarters of an inch lower down was also complete, and the fragment thus 
separated was divided into two, namely, an anterior and a posterior frag- 
ment, by a transverse splitting; the anterior moiety retaining its attach- 
ment to the periosteum below, and not being displaced, while the posterior 
moiety retained its attachment to the periosteum both above and below, 
and was pushed downwards by the descent of the manubrium. His 
mind was clear, but he had paralysis of the bladder, and was breathing 
witli some embarrassment. I had no difficulty in diagnosticating the 
dislocation of the third cartilage, and of the manubrium. There was no 
swelling or discoloration on the front of the chest, but it was quite tender. 
His head was not thrown forwards. He complained of some soreness on 
the back of his head. His general condition was such that I did not 
attempt reduction. The following day he expectorated blood, and on the 
third day he died. The autopsy revealed some effusions of blood under- 
neath the pleura, but no lesions of the heart or lungs. The evidence is 
in this case conclusive that he struck upon his hack and head, in fact. 
that it was a fracture from counter-stroke, by which the head, neck, ami 
three or four upper vertebrae were bent forwards with great force, thus 
doubling forwards the top of* the sternum. 

Dr. Robert Wan-. Jr., of this city, has reported a very similar case, 
in which death occurred on the same day. The fragments of* the sternum 
were not displaced, hut the ribs had Buffered similar Lesions. 1 

Diagnosis. — Tn a few cases the patients have felt the bone break al the 
moment of the accident. When displacement exists, il may generally be 
easily recognized, and the lower fragment will often he seen t<> move 
forward- and backwards ;it each inspiration and expiration. Crepitus 
may also be detected in some of these examples. To detennine it- exist- 
ence, the hand should he placed over the* supposed seal of fracture, while 
the patient is directed to make forced inspirations and expiration-, or tie- 
ear may be applied directly to the chest 

\v ■•- Am,. lied. Times, wo), iii. p. 56. 



200 FRACTURES AND DIASTASES OF THE STERNUM. 

Emphysema has, also, occasionally been noticed, indicating usually 
that the longs have been penetrated by the broken fragments. 

The frequent occurrence of congenita) malformations of the sternum 
should warn us to exercise great care in our examinations, lest we mis- 
take these natural irreL ularities for fractures. The point of junction of 
the first ami second portions has also occasionally been observed to be 
somewhat projected forwards in cases of chronic asthma and emphysema 
of tlu Lungs. Bransby Cooper mentions a remarkable instance of mal- 
PormatioD of the xiphoid cartilage which he at first suspected to be a 
fracture. It was so much curved backwards that, as Mr. Cooper thinks, 
it> pressure upon the stomach produced a constant disposition to vomit 
whenever he had taken a full meal, or had taken a draught of water. 1 

Prognosis. — In simple fracture or diastasis of this bone, uncomplicated 
with lesions of the subjacent viscera, and especially when the separation 
i- the result of muscular action or of a counter-stroke, no serious con- 
sequences are to be apprehended. The bone unites promptly by osseous 
or fibrous tissue, even where it is found impossible to bring its edges into 
apposition. Indeed, generally, where the fragments have been once 
completely displaced, although it is not difficult to replace them momen- 
tarily, a redisplacement soon occurs, and they are found finally to have 
united by overlapping; but no evil consequences usually result from this 
malposition. In nearly all of the cases reported in which palpitations, 
difficult breathing, etc., have been charged to the persistence of the dis- 
placement, the injuries were of such a character as to furnish for these 
unfortunate results other and much more adequate explanations. In one 
instance only, already mentioned, serious inconveniences followed from 
a displacement of the cartilage backwards. 

In other cases, however, where the fracture is the result of a direct blow, 
the prognosis is often very grave; a conclusion to which one would 
naturally arrive from the fact already stated, that the fracture of the 
sternum thus produced, in itself implies the application of great force. 

An abscess occurring in the anterior mediastinum, and caries or necrosis 
of the bone, are among the most common results of a blow delivered 
directly upon the sternum; complications which generally end sooner or 
later in death. Blood may lie also extensively effused into the anterior 
mediastinum. 

A remarkable case of recovery after gunshot injury of the sternum is 
reported by the I'. S. Medical Bureau: 

Private C. Betts, 26th N. J. Vols., set. 22, was struck by a three- 
ounce grapeehot, May 3, 1863, in the charge upon the heights at Fred- 
ericksburg, V;i. The ball comminuted the sternum, opposite the third 
lib on the left side, penetrating the costal pleura. The patient removed 
the ball from the wound himself. On the following day he was admitted 
to the hospital of the second division of the sixth corps. Through the 
wound the arch of the aorta was distinctly visible, and its pulsations could 
be counted. The left lung was collapsed; when sitting up, there was but 
slight dyspnoea. Several fragments of the sternum were removed. The 
■! soon began to heal, and he made a complete recovery. 2 

1 P>. Cooper, Princ. and Pract. of Surg., p. 359. 

2 Circular No. 6, Washington, D. C, Nov. 1, 1865, p. 23. 



FRACTURES AND DIASTASES OF THE STERNUM. 201 

Where emphysema is present, we may anticipate inflammation of the 
pleura and of the longs. 

In several instances, where death lias occurred speedily after the injury, 
the heart has been found penetrated and torn by the fragments. Sanson 
and Dupuytren have each reported one example of this kind. Duverney 
has mentioned two. and Samuel Cooper says there is a specimen in the 
museum of the University College, exhibiting a laceration of the right 
ventricle of the heart by a portion of fractured sternum. Watson mentions 
a case in which the pericardium was torn, but the heart was only contused. 1 

Treatment. — When the fragments are not displaced, the only indica- 
tions of treatment are to immobilize the chest, and to allay the inflam- 
mation, pain, etc., consequent upon the injury to the viscera of the chest. 
The first of these indications is accomplished, at least in some degree, 
by inclosing the body, from the armpits down to the margin of the float- 
ing ribs, with a broad cotton or flannel band. A single band, neatly 
and snugly secured, and made fast with pins, is preferable to, because it 
is more easily applied than, the roller which surgeons have generally 
employed : it is also much less liable to become disarranged. It should 
be pinned while the patient is making a full expiration. To prevent its 
sliding down, two strips of bandage should be attached to its upper mar- 
gin, and crossed over the shoulders in the form of suspenders. 

Generally the patients prefer the half-sitting posture, witli the head 
and shoulders thrown a little backwards; and this is the position which 
will be most likely to maintain the fragments in place, and also to secure 
immobility to the external thoracic muscles, while it leaves the diaphragm 
and the abdominal muscles free to act. 

The second indication may demand the use of the lancet; but more 
often it will be found necessary to allay the pain and disposition to cough 
by the use of opium. 

If. however, the fragments are displaced, it is proper first to attempt 
their reduction: which, as I have already intimated, is generally more 
easy of accomplishment than is the maintenance of them in place until 
a cure is effected. 

The fragments may sometimes be made to resume their natural position 
by a single full inspiration, but then they usually fall back during ex- 
piration ; or they may be reduced by straightening the spine forcibly, 
and at the same time drawing the shoulder- back. 

Verduc and Petit proposed, in those cases in which it was found im- 
possible to reduce the fragments by these simple means, t<> cut down and 
lift the depressed bone. Nelaton suggests tli<- use of ;i blunl crotchet 
introduced through a narrow incision: and Malgaigne has thought of 
another plan, which is, to penetrate the -kin with ;i punch, and directing 
it to the broken nun-gin. to push the fragment into its place, but which 
he does not himself regard ;i- ;i suggestion of much value, since the bone 
is too soft to afford the necessary resistance; and, moreover, this, in 
common with all of tie- other similar methods, is liable, in some degree, 
to the objection that it may increase the tendency t<» caries and suppura- 
tion, already imminent, if reduced, the fragments will probably imme- 

1 Watson, Sev> York Journ. of Med. vol. iii. )>. 851. 



202 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

diately again become displaced; and, more than all, it still remains to 
be proved conclusively thai the mere riding of the fragments is in itself 
ever a cause of Bubsequenl suffering, or even of inconvenience. 

When an abscess has formed in the anterior mediastinum, surgeons 
have occasionally recommended the use of the trephine. Gibson has 
twice operated in this maimer at the Philadelphia Hospital, but in each 
case the caries continued to extend, and the patient died; an experience 
which has inclined him latterly to discountenance the operation. 1 

There are other considerations mentioned by Lonsdale, which ought 
to decide us never to use the trephine in these cases. "For the symp- 
toms denoting the presence of the abscess, when completely confined to 
the under surface of the bone, will be very uncertain; and when the 
matter collects in large quantities, it will show itself at the margin of the 
Bternum, between the ribs, when it can be let out by making a puncture 
with the point of a lancet, without the necessity of removing a portion 
of the hone.'-' Ashhurst, referring to the same point, remarks: "The 
fact thai the mediastinal space can be cut into without injury to the 
pleura is shown by many eases, among others by one which came under 
my own observation." 3 



CHAPTER XVIII. 

FRACTURES OF THE RIBS AND THEIE CARTILAGES. 
§ 1. Fractures of the Ribs. 

FRACTURES of the ribs, observed more often than fractures of the 
Bternum, are rare as compared with fractures of other long bones. 

In my records, not including fractures from gunshot injuries, only 
thirty-two patients are reported as having had broken ribs; but, as in 
several of the cases, two or more ribs were broken at the same time, the 
total Dumber of fractures is about sixty-five. If, however, I had always 
accepted the diagnosis made by other surgeons, the number would have 
been much greater, Bince J have been repeatedly assured that the ribs 
wen- broken when, upon the most careful examination, no evidence, 
beyond the existence of ;i severe pain and of difficult respiration, has 
been presented to me. 

Etiology. — The force requisite to break the ribs is scarcely less than 
wh;ii ig requisite t<> break the sternum: and in childhood and infancy it 
i- sometimes almosl impossible to break them, so that children and even 
adult- are often crushed and killed outright, where, although the pressure 
ha- been directly upon the thorax, the ribs have resumed their positions, 
and have been found not to he broken. I have met with several exam- 
plea of this kind. 

1 Gibson, [nstitutea and Practice of Surgery, vol. i. p. 269. 

Lonsdale, Practical Treatise on Fracturcs/London, 1838, p. 242. 
; Ashhurst, Am. Journ. Med. Sci., Jan. and Oct. 1862. 



FRACTURES OF THE RIBS. 203 

In old age the cartilages ossify, and the ribs themselves suffer a gradual 
atrophy, which renders them much more liable to break. 

The most common causes are direct blows, of very great force, in con- 
sequence of which sometimes the fragments are not only broken, but- 
more or less forced inwards: occasionally they are the result of counter- 
strokes, and then the fragments, if they deviate at all from their natural 
position, are salient outwards; a species of fracture which I have not 
met with so often. 

Malgaigne has collected eight examples of fractures of the ribs pro- 
duced by muscular action, by the beating of the heart, etc., all of which 
occurred upon the left side. In six additional cases collected by M. 
Paulet, the fractures were upon the right side. Three of these were 
caused by coughing, and two by a sudden movement of the body. It is 
believed, however, that in all of these cases the ribs had previously be- 
come atrophied, and perhaps undergone other changes in their structure, 
rendering them liable to fracture from the action of trivial causes. Mor- 
selli attributes the frequency of fracture of the ribs in the insane to 
trophic changes in the structure of the ribs, dependent upon lesions of 
the nervous centres. 1 

Pathology, Seat, etc. — The fourth, fifth, sixth, and seventh ribs are ' 
most liable to be broken; the upper ribs, and especially the first rib, 
being so well protected in various ways as to diminish greatly their lia- 
bility, while the loose and floating condition of the last two ribs gives 
them an almost complete exemption. 

Malgaigne has noticed, also, contrary to the general opinion of sur- 
geons, that the ribs are most often broken in their anterior thirds, whether 
the cause has been a direct or a counter blow. My own observations 
confirm this statement. 

The direction of the fracture is generally transverse or slightly oblique : 
sometimes it is quite oblique. It is often compound; and in a few in- 
stances I have found it comminuted or multiple. Where the fracture is 
compound, it is rendered so generally by the fragments having penetrated 
the lungs, and not by a tegumentary wound. 

Displacement cannot occur in the direction of the axis of the bone 
unless several ribs are broken at the same time. The fragments are 
therefore either not at all displaced, or they fall inwards toward the 
cavity of the chest, or outwards, or very slightly downwards, in the 
direction of the intercostal spaces. Sometimes the rib rotates a little 
upon its own axis. 

Prognosis. — Death occurs sooner or later in a pretty large minority 
of the cases in which the ribs have been broken; yet not often as a 
direct consequence of the fracture, but only as ;i result of the injury 
inflicted upon the viscera of the chest, or of other injuries received al the 
same moment. The violent compression of the heart and lung- has fre- 
quently produced death, and sometimes, as 1 have more than once seen, 
almost immediately; or the patients have succumbed al a later period to 
acute pneumonitis, or pleuritis. 

Lonsdale saw a case in which, the body of a man having been traversed 

1 Paulet. Morselli, French ed. of this treatise, 03 Poinaot. 



FRACTURES OV TIIK RIBS AND THEIR CARTILAGES. 

by the wheel of a wagon, eight ribs were broken, and. death having fol- 
lowed almost immediately, the autopsy disclosed a rent in the left auricle 
«»t* the heart, produced by one of the broken ribs. 1 South says there is 
Buch a specimen at St. Thomas's Hospital. 8 

Dupuytren reports a similar case. The same surgeon lias also seen 
several deaths produced by the emphysema, independent of the fracture, 
two of which are particularly described in his Clinical Lectures. 3 Ames- 
bury has seen a case of death from rupture of the intercostal artery. 
where there was no injury of the lungs. 4 

M. Paulet has studied a series of examples of rupture of this artery in 
connection with fracture of the ribs, obtained from various sources, and 
has drawn the following conclusions: First, lesions of the intercostal 
artery in this class of accidents is much more frequent than is generally 
supposed. Second, the lesion is always grave, and often mortal. Third, 
it may occur Dot only after comminuted fractures, but after simple, and 
even after incomplete fractures, provided the fracture is on the lower 
border of the rib. 5 

In several instances observed by me, patients have suffered from pains 
in the side, occasionally from cough, etc.. after the lapse of two or more 
year-, and I Buspect it is no uncommon thing for these injuries to entail 
some such permanent disability, but which is a consequence rather of the 
injury to the viscera of the chest, than of any condition of the broken 
ribs themselves. 

In general, simple fractures of the ribs unite in from twenty-five to 
thirty days. Malgaigne has seen one case of non-union; Huguier met 
with another upon the cadaver, in which a complete false joint existed. 
furnished with a capsule and lined with synovial membrane; 6 Eve, of 
Nashville, Tenn., saw a case of non-union, occasioned, probably, by a 
caries or necrosis of the bone, since it was accompanied with a discharge 
of matter, and in which a removal of the ends of the fragments resulted 
promptly in a cure of the sinus; 7 and Samuel Cooper says there is a 
Bpecimen in the Museum of the University College, of a fracture of six 
rib- where the fragments are only connected by a fibrous or ligamentous 
tissue. 8 

Barrit, Lisfranc, Trelat, and Demarquay have reported similar ex- 
am) i 

The union generally occurs with only a slight degree of displacement. 

After the onion is completed, even where there is no displacement, a 
certain amount of* ensheathing callus may generally be felt at the point 
of fracture. < >f five cases which I have carefully examined after recovery, 
in only one instance was I unable to detect any irregularity at this point. 
I have in my cabinet nine specimens of fractured ribs, in four of which 
the ensheathing callus is completely formed, but the fragments are in 
perfect apposition: in one, apposition is preserved, but there is no en- 
Bheathing callus; and the remaining four, all occurring in the same 

2 Chelius's Surgery, by South, vol. i. p. 599. 
uytren, • ■).. <it.. p ■ Amesbury on Fractures, vol, ii. p. 612. 

op 'it-. 1»- 200. '• Bfalgaigne, G p gft^ p 435 

v V. Journ. ftfed., vol. w. p. 136. 
9 ' ... v<.l. ii. j». 321. » Poinaot, op. cit., p. 201. 



FRACTURES OF THE RIBS. 



205 



person, are united with displacement, but without a proper ensheathing 

callus. 

In some specimens I have observed sharp spicula, in others broader 

sheers of bone extending along the course of the intercostal muscles from 
one rib to the other, forming a species of anchylosis between their ad- 
jacent margins. 

Symptomatology. — Acute pain, referred especially to the point of frac- 
ture, sometimes producing great embarrassment in the respiration, and 
crepitus, are the most common indications of a fracture. The pain and em- 



Fig. 47. 




Fractured ribs joined to each other by osseous matter. (From Dr. Gross's cabinet.) 

barrassed respiration are, however, far from being diagnostic, since they 
are often present in an equal degree when the walls of the chest have only 
been severely contused. 

The crepitus, also, is often difficult to detect, owing to the thickness of 
the muscular coverings, or to the amount of fat upon the body, or to the 
fracture having occurred perhaps directly underneath the mammae in the 
female. In three instances, where the presence of emphysema rendered 
the existence of a fracture quite certain. I have been unable immediately 
after the accident to discover crepitus. 

The crepitus may be discovered sometimes by pressing gently upon the 
seat of fracture or by applying the ear or the stethoscope over this point 
while the patient attempts a full inspiration, or coughs; or we may press 
upon the front of the chest with one hand, while the fingers of the other 
hand rest upon the fracture. 

Occasionally the patient has felt the bone break, and very often he 
feels or hear- the crepitus after it is broken, and will himself indicate 

very clearly the point of fracture. 

At the -nine time that we detect crepitus we aiv able also to discover 

motion in the fragments, but 1 have once or twice discovered preternatural 
mobility without crepitus. 

Emphysema, which is almosl certainly indicative of ;i fracture, is 
present in a pretty large proportion of cases. It bas been observed by 
me in 13 out of d2 cases; generally it did not extend over more than 
two or three square feet of surface; but in two cases it finally extended 
over nearly the whole body. It is remarkable, however, that in only four 
of these thirteen cases did the patients expectorate blood, and then in a 
very small quantity, and usually not until the second or third day. 

Desaull observes that emphysema rarely succeeds to fractures of tne 



206 FRACTUBKS OF THB RIBS AND THEIR CARTILAGES. 

ribs; an observation which, as "will be seen, my experience does not 
confirm. 

Treatment, — In simple fractures, where there is no displacement, or 
where the displacement is only moderate, the chest may be inclosed with 
a broad belt <>r band, as we have already directed in case of fracture of 
the sternum; provided always that it is not found to increase instead of 
d iminishin g the patient's sufferings. Some patients cannot tolerate this 
confinement at all; whilst, with a majority, although it is at first uncom- 
fortable and oppressive, after an hour or two it affords great relief from 
the distressing pain, and they will not consent to have it removed even 
for a moment. In nearly all cases of comminuted fracture it is inad- 
missible, on account of its tendency to force the pieces inwards. 

Ilannay, of England, has suggested the use of adhesive strips as a 
substitute for the cotton or flannel band; the several successive pieces 
being imbricated upon each other until the whole chest is covered. 1 
Tin same objection holds to this mode of dressing as to a similar mode 
of dressing a broken clavicle, which has been recently recommended. 
It will certainly become loosened after a few hours, by the slight but un- 
interrupted play of the ribs, and it is not as comfortable as a woollen or 
cotton band. 

The forearm ought also to be brought across the chest at a right angle 
witli tbe arm, and secured in this position with a moderately tight bandage 
or Bling, so as to prevent any motion in the pectoral muscles. 

A- t<> position, the patient generally prefers to sit up, or he chooses a 
position only partly reclining upon his back ; but there is no positive rule 
to be observed in this matter, except that such a position shall be chosen 
;i- shall prove most comfortable to the patient. 

If tbe fragments are salient outwards, the fracture having been pro- 
duced by a counter-stroke, they may be reduced by pressing gently upon 
them from without. If, on the contrary, the fragments are salient inwards, 
they will be found, in a great majority of cases, to have resumed their 
positions spontaneously or through the natural actions of respiration ; 
but if they have not. it will be exceedingly difficult to restore them. 
Possibly it may be accomplished by pressing forcibly upon the front of the 
chest, or upon tbe anterior extremity of the broken rib; yet if the frag- 
ments are comminuted, and the ends are much driven in, this method 
will avail little or uothing. In such cases several surgeons have recom- 
mended that we should cut down to the bone and elevate the fragments, 
but Rossi alone claims to have actually put the suggestion into practice. 

No doubt, if tlic necessity were urgent, this method might be success- 
fully adopted ; or, instead of cutting down to the broken rib, we might 
oven seize the fragment with a book, as suggested by Malgaigne, or what 
m some cases might be even more convenient, with a pair of forceps 
constructed with Ion-- teeth, obliquely set upon a firm shaft. Yet the 
exigency which will demand a resort to any of these measures will be 
edingly rare. In gunshot fractures, which are nearly all compound 
and comminuted, the Loosened or detached fragments should be at once 
removed. 

1 Ain.-r. J. .mi.. Med, Si., vol. \x\ix. p. 198. From Lond. Med. Gaz., Nov. 1845 



FRACTURES OF THE RIBS. 207 

In no case do I attach any value or importance to the advice giveD by 
Petit, that we shall place a compress upon the front of the chest, under- 
neath the bandage, in order to reduce the fragments, or to retain them in 
place after reduction. Lisfranc. who advocated this method, claimed that 
its advantage consisted in the increased length which was thus given to 
the antero-posterior diameter of the chest, and the consequent accumula- 
tion of pressure from the encircling band, in this direction. 1 The mechan- 
ical law is no doubt correctly stated, but its value in practice is too incon- 
siderable to deserve consideration, 

The emphysema generally demands no special attention, since it is 
usually too limited to occasion inconvenience ; and when more extensive, 
it generally disappears spontaneously after a few days, or a few weeks at 
most. The advice given by some surgeons, that we ought in these cases 
to cut down to the pleural cavity so as to allow the air to escape freely 
through the incision, seems thus far to have rested its reputation upon a 
more than doubtful theory rather than upon any testimony of experience. 
Abernethy alone, so far as I know, has actually made the experiment, 
and his patient died. 

Dupuytren, in the two cases already alluded to, bled the patients and 
applied resolvent liquids, with rollers ; he also made incisions with the 
lancet at various points of the body, more or less remote from the seat 
of fracture, a practice, however, in which he confesses he has no confi- 
dence whatever. These patients both died. 

Dr. Stedman, of the Massachusetts General Hospital, has reported the 
case of a man aged sixty-nine, of intemperate habits, who, in addition 
to a fracture of one of his ribs, had also a dislocation of the outer end of 
the clavicle. The emphysema commenced immediately, and reached its 
acme on the twenty-second day. At this time it had extended over his 
whole body ; his eyes were closed, and he breathed with great difficulty; 
but on the forty-fifth day the emphysema had entirely disappeared, and 
he was dismissed cured. The treatment consisted chiefly in the free in- 
ternal use of stimulants, and in the application of bandages ; but the 
bandages soon became disarranged, and after a few days they were 
entirely laid aside. 2 

In the case of one of my own patients, where the emphysema was 
almost equally extensive, the patient recovered after a few weeks, under 
the use of a simple diet, and without any special medication whatever. 
The second case of extensive emphysema observed by me was as follow.-: 
A man was crushed under a bank of earth Sept. lit, 1800. Two hours 
after the accident I found him greatly prostrated. Six ribs were broken 
on the left side near the spine, and one on the right side. In coughing 
he expectorated some blood. There was emphysema of the face and o\ Ti- 
the front of the chest. He died at 9 p.m., having survived the accident 
only about six hours. The autopsy showed the h-f't lung penetrated at 
two points, and collapsed : about -ix ounce- of blood in the left pleural 
cavity; lower lobe of right lung crushed and disorganized, hut the 
remainder of the lung not collapsed. The features of the face were 

1 Ranking'e Abstract, vol. ii. p. 204, from Gaz. dee Hdpitatix, Jul] 8, 1846. 

', Med. and Sur.:. Journ., vol. lii. p. 816. 



208 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

almost obliterated by the emphysema, which had also invaded the medi- 
astinal space, and extended over the body as low as the knees. 

§ 2. Fractures of the Cartilages of the Ribs. 

Boyer was incorrecl when he said that the cartilages of the ribs could 
not be broken until they were ossified. They are often broken when 
there is do ossification, at the same time that the ribs themselves are 
broken. Sometimes they arc broken alone. Not unfrequently, also, the 
separation takes place at the precise point of junction between the car- 
tilage and the bone. G. Puel infers, from experiments upon the cadaver, 
thai the fracture would take place at this point most often. 1 

Pyper relates a case in which the sternum was broken in a man aged 
twenty-five years, and also the cartilages of the sixth, seventh, and eighth 
ribs of the right side, as was proved by the autopsy, yet the cartilages 
were not ossified. The vena cava ascendens was also ruptured by the 
force of the compression. 1 The reader is referred also to my own and 
Dr. Watts's cases reported in the chapter on " Fractures of the Sternum. " 
Since the date of the report of these cases I have met with several 
examples of fracture of the cartilages. 

Etiology. — The causes are the same as those which produce fractures 
of the ribs, yet it is generally understood that it will require greater 
force, and that consequently the injury done to the viscera of the thorax 
will be more complicated and intense. 

In the reports of the Massachusetts General Hospital an account is 
given of the case of a man aged thirty, who was crushed by the fall of 
a heavy weight upon his body, and who died after about sixty hours. 
An examination after death revealed a fracture of the cartilages of the 
third and fourth ribs, with a laceration of the intercostal muscles to such 
an extent that a hernia of the lungs had occurred at this point. This 
hernia had been discovered and recognized by Dr. Warren soon after the 
accident occurred : the protrusion being at that time as large as the 
clenched fist, and regularly rising and falling with each movement of 
respiration. It was accompanied, also, with a moderate emphysema. 

Pathology, — The fracture is clean and vertical, or transverse; never 
irregular or oblique. The direction of the displacement varies as in 
fractures of the ribs, hut the anterior or sternal fragment is generally 
found in front of the posterior or spinal. 

I nion takes place in these fractures, according to the testimony of 
most pathologists, not through the medium of cartilage, but of bone. 
Sometimes the new bone is deposited only between the ends of the frag- 
ments, in the form of ;i thin plate; at other times it is formed around 
the fragments ;i- well as between them. The latter of these two processes 
has been mosl frequently observed. The ensheathing callus appears to 
he supplied by the perichondrium, whilst the experiments of Dr. Redfern 
render it probable that the intermediate callus may result from a conver- 
sion or transformation of the adjacenl cartilaginous surfaces. Paget 

Puel, I' ic. dee cart. cost. Anvero, 1876. 

king'a Abstract, v..]. i. p. 147. from the Lancet, Oct. 1844. 



FRACTUEES OF THE CLAVICLE. 209 

remarks, also, that the ossification extends to the parts of the cartilage 
immediately adjacent to the fracture. 

According to Poinsot, in 1869, H. Peyraud related in his thesis 
several experiments showing that, in animals, some portions of the costal 
cartilages nearly four centimetres long having been taken oft*, they may 
be entirely reproduced, if care has been taken to save the perichondrium, 
and a case has been published by Bassereau showing that in man the 
extremities of a broken cartilage may unite by fibro-cartilaginous tissue. 
In reference to the experiments of Peyraud, it must be said that we can 
make no positive inferences as to the process of repair in man from ob- 
servations made upon other animals. 

I have seen one example, in the person of Hiram Leech, ret. 38, 
which, after the expiration of more than one year, had not united. The 
fracture had occurred in the united cartilages of the ninth and tenth ribs. 
The posterior fragment overlapped the anterior, and they played freely 
upon each other at each act of inspiration and expiration. 

I do not know that any observations have been made upon the repair 
of these cartilages in very early life, and it is possible that the process 
may differ from this, which has been described as it has been observed in 
the adult. 

Treatment. — The treatment need not differ from that already recom- 
mended for fractured ribs. 






CHAPTER XIX. 

FRACTURES OF THE CLAVICLE. 

For the sake of convenience, I shall divide fractures of the clavicle 
into those occurring through the inner, middle, and outer thirds. By 
the " outer third " is meant all that portion of the clavicle included be- 
tween its scapular extremity and the internal margin of the conoid liga- 
ment. The remaining portion is intended to be divided equally into 
two separate halves. The peculiarities of these several, portions, in 
respect to anatomical relations, liability to fracture results, etc., will 
explain the propriety of the divisions. 

(''/uses. — If we except gunshot fractures, the clavicle is broken, in a 
large majority of cases, by ;i counter-stroke, such as ;i fall, or n blow 
upon the extremity of the shoulder. 

Occasionally it is broken by ;i direct stroke, ;is when <\ bkrw aimed ;it 
the head is received upon the shoulder; it is broken sometimes bj 'lie 
recoil of an overloaded gun, especially when the person lies upon the 
ground, with tli<- butt of the gun resting against the clavicle. 

Gibson has Been a case in which it was broken in ;t child at birth, by 

14 



210 PKACTURBS OF THE CLAVICLE. 

an ignorant midwife pulling at the arm, 1 and Dr. Atkinson has reported 
an example of intra-uterine fracture of the clavicle. 2 

(Jurlt has collected seven cases of intra-uterine fracture of the clavicle 
caused by external violence. 8 

1 have «»ncc Been the clavicle broken by muscular action alone. A 
large, well-built, and healthy man, aged thirty-seven, standing upon 
the -round, attempted to secure the braces of his carriage-top with his 
right arm. when lie felt a sudden snap, as if something about his shoulder 
had given way. lie did not, however, suspect the nature of the injury, 
and diil not consult any surgeon until eight days after, at which time 
I found the right clavicle broken near its centre, but rather nearer the 
Menial than the scapular extremity. The fragments were but slightly, 
if at all, displaced, but motion and crepitus at the point of fracture were 
distinct. A node-like swelling was also present, indicating the existence 
of a considerable amount of ensheathing callus. He had been unable to 
raise the arm to a right angle with the body since it was broken, but he 
had suffered no other inconvenience from it. 

A similar case is reported in the number for January, 1843, of the 
Arm rican Journal of Medical Sciences, copied from the Revista Medica. 
The subject of this case was a colonel of cavalry, about sixty years of 
age. In mounting his horse, he experienced a sensation as if something 
had broken, followed by acute pain in his left shoulder, and, on exam- 
ination, it was found that the clavicle was fractured in the middle. The 
health of this gentleman had been impaired, it is further stated, by re- 
peated attacks of syphilis. 

W. E. Whitehead, U. S. N., has reported the case of a healthy and 
muscular man, twenty-eight years old, who broke his left clavicle at the 
junction of the outer and middle thirds, while attempting to raise him- 
self to ;i platform eight feet high. The fracture was transverse, and un- 
accompanied with displacement. 4 

Malgaigne ha- recorded three other examples of fracture of this bone 
from muscular action ; and Parker saw a case which was produced by 
striking ;tt a dog with a whip. The bone, in the latter case, had been 
previously somewhat diseased, yet it united favorably. 5 

Of these Beven cases, five occurred on the right side, and always near 
the middle of the hone, if we except one case reported by Malgaigne, in 
which the point of fracture is not mentioned. In neither case did the 
fragments become displaced, only as they were found, in some of the 
examples, inclined Blightly forwards. 

Gurll has collected twenty cases of fracture from this cause. 6 

Dr. Pooley reports an example of fracture of the clavicle in a child, 
supposed t<. have been due to muscular action, and which was the result 

1 Gibson, Principles of Burg., Bixth cd., vol. i. p. 272. 
1 Atkine B Ifed. and Surg. Journ., July 26, 1860. 
t, Bolmes'e Surgery, ed. of 1870, vol. ii. p. 765. 
Whitehead, Pacific Sled, and Surg. Journ., 1871. 
■ V. Journ. Med , July, 1852. 
It, Holmee'a Surgery, ed. of 1*70, vol. ii. p. 765. See also paper by M. Deleus 
ictures of the Clavicle from Muscular Action, in Archives Grdnerales, March, 
1876. 



FRACTURES OF THE CLAVICLE. 



211 



of a foil upon the back. 1 It does not appear to me absolutely certain 
that in the latter ease the manner of the foil was determined, and that it 
could be fairly set down as due directly to muscular action. 

Pathology. — It has already been observed, in speaking of partial 
fractures, that this bone suffers an incomplete fracture more often than 
any other, and that in such cases the lesion occurs generally in the 
middle third, or rather to the sternal side of the centre, and in a direc- 
tion nearly or quite transverse. They are not usually accompanied with 
much displacement ; but if a displacement exists, it is a slight forward 
inclination of the fragment.-. 

Fractures which are complete occur mostly after the bones have be- 
come firm and unyielding. They are also generally oblique, seldom 
comminuted, still more rarely compound. The point of the clavicle at 
which a complete fracture usually occurs is at or near the outer end of 
the middle third, and a little to the sternal side of the cora co-clavicular 
ligaments, near where the trapezius and deltoid cease their attachments. 
It might be more exaet to say that the fracture extends from this point 
downwards and inwards, toward the sternum, embracing one inch or less 
of its entire length. In some eases the obliquity is greater, and the 
amount of bone involved is much more considerable. 

Why the bone should break more frequently at this point, especially 
in the adult and in the male, it is not difficult to understand. It is 
smaller here than elsewhere, and less supported by muscular and liga- 
mentous attachments. At this point, also, the axis of the bone begins 
pretty abruptly to curve forwards, and 
more abruptly in the adult and male 
than in the child and female. When, 
therefore, the clavicle is broken, as it 
usually is, by a counter-stroke, the 
force of the blow, conveyed from the 
shoulder through the outer portion of 
the bone, is suddenly arrested, and ex- 
pends itself upon the point where the 
direction of the axis is changed. 

In a record of one hundred and fifty- 
seven fractures, including partial and 
comminuted, and not including gun- 
shot fractures, one hundred and twenty- 
seven have occurred through the mid- 
dle third: and, with the exception of* 
the partial fracture.-, the fracture has 
in oearly all of the cases taken place 
near tie- outer end of this third. Four 
have occurred through tie- inner third, 
three of which were within one inch 

of the sternum ; and seventeen through the^outer third. A more prac- 
tical analysis can be based, however, upon the point of fracture with 
reference to it- cause; and 1 have never, but once, seen ;< complete 



Fig. 48. 




Complete oblique fracture of clnvide. 



* J. H. Pooler. Prof. - _ Starling Med ColL, Columbus, Ohio. A Clinical 

Lecture. 1*77. 



212 FRACTURES OV THE CLAVICLE. 

fracture of this bone, in the adult, produced clearly by a counter-stroke, 
which was uot uear the outer cud of the middle third. 

When the fracture is at this point, or in any portion of the middle 
third, the direction of the displacement is almost uniformly the same. 
The Menial fragment is slightly lifted by the action of the clavicular 
portion of the Bterno-cleido-mastoid muscle, notwithstanding the resist- 
ance "1* the rhomboid Ligament, the pectoralis major and the subclavius 
muscles. On the other hand, the acromial fragment is dragged down- 
wardfi by the weight of the arm, aided by the conjoined action of a por- 
tion of the pectoralis major and the latissimus dorsi, feebly resisted by 
the trapezius and other muscles from above; by the action of the same 
muscles, aided by the pectoralis minor, and perhaps by some portion of 
the subclavius, it is drawn toward the body, diminishing thereby the 
axillary space : while by the preponderating strength of the pectoralis 
major and minor, the acromial end of the fragment, with the shoulder, 
is drawn forwards: the sternal end of the same fragment being rather 
displaced backwards, and at the same time resting at a point somewhat 
elevated above the acromial end. 

Desault has recorded one example of an overlapping by the elevation 
of the acromial fragment over the sternal; 1 and Bichat remarks that 
Hippocrates speaks of the phenomenon as a thing which was familiar to 
him. Syme has mentioned a case of this kind which he had seen. 2 
Grueretin, Malgaigne, 3 and Stephen Smith have each reported an ex- 
ample. 4 In Stephen Smith's case the fracture occurred in a man thirty- 
eight years old. The bone was broken through the outer third, and 
transversely. He was treated at the Bellevue Hospital, but the over- 
lapping, to the extent of one inch, remained after the cure was com- 
pleted. 

Margaret O'Donnell, aet. 40, was admitted to the Charity Hospital, 
BlackwelTs Island, June 1, 1868, with a single fracture of the clavicle, 
uear its middle, caused two weeks before, by a fall on the shoulder. 
The sternal fragment was lying beneath the acromial, and in this position 
it finally united. 

In nearly all cases of oblique fractures occurring through the middle 
third there follows immediately an overlapping, varying from one-quarter 
of an inch to an inch, and sometimes, though very rarely, exceeding 
this : the average shortening being about half an inch. There is a speci- 
men in the Dupuytren Museum, in which the shortening equals one- 
third of its entire length. 

Transverse fractures, wherever they may occur, whether in children 
or adult-. ;ire seldom found displaced, at least in the direction of the 
axis of the bone, as the following examples will illustrate, and they 
unite usually withoul shortening or deformity : 

An old lady, aged eighty years, fell down a flight of stairs, breaking 
the righl clavicle transversely, about one inch from the sternum. I saw 
her, with I)]-. Trowbridge, on the day following the accident. Motion 
and crepitus \\ ere distinct, hut there was scarcely any displacement. No 
dressings were applied, hut Bhe was directed to keep quiet in bed, and 

Desaulton Pnc, op. cit., p. 16. 2 Amer. Journ. Med. Sci.,vol. xvii. p. 251. 

' N ' &aign< • op. cit, ]>. 461. 4 X. V. Journ. of Med., .May, 1857. 



FRACTURES OF THE CLAVICLE. 213 

upon her back. In the usual time the fragments had united, without 
deformity. 

A man. about forty years old. fell backwards from a wagon, breaking 
the collar-bone near the middle. The fragments were movable, but not 
displaced. He was treated successfully and without any resulting de- 
formity, by simple confinement in the recumbent posture during a few 
days, and after this by suspending the arm in a sling, while lie was per- 
mitted to walk about. 

A young man. aged twenty-six. fell while wrestling and broke the 
clavicle at the outer end of the middle third. There was some dis- 
placement at first, but the fragments, being reduced, were found to sup- 
port themselves. A cross, secured with straps, was applied to the back, and 
on the twenty-eighth day the union was complete, and without deformity. 

A child, aged three years, fell about six feet, striking upon his shoulder. 
He was sent to me on the same day. by Dr. G. Burwell. I found the 
left clavicle broken off completely, about one inch from its scapular end. 
Crepitus and motion were distinct, but the fragments were not displaced. 
The arm was placed in a sling, and on the seventh day both motion and 
crepitus had ceased. The cure was accomplished without any decree of 
displacement. 

The example of a fracture from muscular action, already mentioned as 
having been seen by me. was also probably transverse, and union has 
occurred without treatment and without displacement. 

Stephen Smith, of Xew York, has met with two examples of trans- 
verse fractures without displacement, in a hospital record of eleven cases. 
Bichat says Desault has frequently observed the same, it having been 
seen three times at Hotel Dieu. in the course of the year 1787. ! De- 
fault thinks, also, that sometimes the fracture, taking place obliquely 
upwards and inwards, the usual form of displacement is prevented, and 
apposition is preserved. In nearly all of the examples of partial trans- 
verse fractures, occurring in children, seen by me. there has been no 
longitudinal displacement. 

If the fracture is near the Bternum, and within the fibres of the costo- 
clavicular ligaments, as in the case of the old lady just cited, the dis- 
placement is inconsiderable. I have seen one other similar case, in an 
adult also. Lonsdale mention- a case, in ;i child three year- old, which 
came under his observation in Middlesex Hospital, 9 which he regarded 
as a separation of the epiphysis, the point of fracture being half an inch 
from the sternum: but the only epiphysis in connection with this bone, 
is an exceedingly thin plate at the sternal end, which does not begin to 
ossifv until about the eighteenth year of life. Neither the age of the 
patient, nor the point of separation, would justify an opinion that this 
was an epiphyseal separation. Malgaigne mention- two other examples, 
in one of which the fracture was so Dear the Bternum that it was difficult 
to say whether it was nor a partial dislocation. The displacement was 
only trivial/ Hut the only two specimens contained in the Dupuytren 
Museum offer a considerable displacement, and in both the external 
fragment is thrown downward- and forwards. 

1 De-auit -. ••)>• f ;t.- p. !■"•• | 206. 

3 Malgaigne, op. cit., p. 491. 



L>i4 FRACTURES OF THE CLAVICLE. 

March 32, 1865, I presented to the New York Pathological Society a 
similar case, obtained from a patient in Bellevue Hospital. The man 
from whom this specimen was taken was forty-five years old, and the 
fracture, occasioned by a fall upon the shoulder, extended from the 
Bterno-clavicular articulation upwards and outw T ards one inch and a half. 
The fragments were overlapped three-quarters of an inch, and were firmly 
united. The character of the accident was not recognized until after 
death. 'The specimen is now in the museum of the Bellevue Hospital. 

A case is reported from Mt. Sinai Hospital, in this city, of a fracture 
of the clavicle in an adult, at a point about one inch from the sternum. 
The inner fragment was drawn, by the action of the sterno-cleido-mastoid 
muscle, into a vertical position, and the outer was drawn down upon the 
chest. It became apparent that replacement could not be effected with- 
out division of the muscle; and, inasmuch as the displacement caused no 
inconvenience, it was permitted to remain as it was found. 1 

With regard to the amount of displacement usually attendant upon 
fractures near the outer end of the bone, surgical writers have generally 
united in declaring that it was in a majority of cases very inconsiderable, 
while some have even affirmed that there would be found no displacement 
whatever: neither of which opinions, according to the observations of 
Robert Smith, of Dublin, is strictly correct. He has examined eight 
specimens of fracture of the outer extremity of the clavicle, contained in 
the museum of the Richmond Hospital School of Medicine; three of 
which were broken between the conoid and trapezoid ligaments, and are 
united with very little displacement, whilst the remaining five, broken 
beyond the trapezoid ligament, present a very marked deformity. 

The following is a summary of the conclusions to which he has arrived: 
••When the clavicle is broken between the two fasciculi of the coraco- 
clavicular ligament, there is seldom any displacement of either fragment, 
and always much less than in fracture of any other portion of the bone. 
When displacement does occur, it is usually limited to a slight alteration 
in the direction of the bone, by which the natural convexity of this 
portion of the clavicle is increased. 

"The explanation of which facts is found in the attachments of the 
ligaments from below to the two fragments; and in the action of the 
trapezius from above, by which they are antagonized. 

• Bui the case is very different when the bone is broken external to 

the trapezoid ligament. Here the coraco-clavicular ligaments can have 

no direct influence upon the outer fragment, which is displaced now 

partly by muscular action, and partly by the 

weight of the arm, the sternal end of the outer 

fragment being drawn upwards by the clavicular 

poit ion of the trapezius, while, by the action of 

the muscles passing from the chest, the entire 

outer fragment is drawn forwards and inwards, 

so ;i- to bring sometimes its broken surface into 

Praetor* outride ..f trnpe- contact with the anterior surface of the inner 

■old ligament, United, fragment, and placing it nearly at right angles 

Ww York Med. Journ., Jan. 1S77, p. 48. 




FRACTURES OF THE CLAVICLE. 215 

with this fragment, in which position it is generally united. The dis- 
placement in this direction, rather than any degree of overlapping, ex- 
plains also the shortening which existed in all of these cases, varying in 
the different specimens from half an inch to one inch, and averaging 
about three-quarters of an inch." 

Such are the views of Mr. Smith, and I see no reason to call in ques- 
tion their correctness. In my own experience, a fracture occurring in 
a child three years old, within one inch of the acromial end, probably 
between the ligaments, was never displaced at all; a second, and third, 
occurring in adults, presented no displacement. Two cases were dis- 
placed each one-quarter of an inch, and two cases half an inch; these 
four latter cases occurred in adults, and always within an inch of the 
acromial end of the bone. In one of these last examples, the inner 
fragment was rather behind than above the outer fragment. 

But it would be unsafe to draw conclusions from an experience which 
is confined entirely to living examples, and in which no dissections have 
been made, to verify the exact point of fracture, or the precise amount 
and character of the displacement. So far as they go, however, they 
seem to me to confirm the general correctness of the observations made 
by Robert Smith. 

It has happened to me only six times to meet with a comminuted frac- 
ture of the clavicle, except in cases of gunshot injuries, all of which 
fractures occurred through some portion of the middle third of the bone; 
the intercepted fragments being from one inch to one inch and a half in 
length, and lying obliquely, or, as in one case observed by me, at nearly 
a right angle with the main fragments. 

I have never seen a compound fracture of this bone except as the re- 
sult of a gunshot injury, although, in many cases, the sharp point of an 
oblique fracture has seemed just ready to penetrate the skin. 

One case is reported as having been presented at St. Bartholomew's 
Hospital. It occurred in a boy fourteen years old, and was produced 
by his having been drawn into some machinery while it was in motion. 1 
Two similar cases are reported from the New York Hospital, as having 
been observed during the last ten years preceding the date of the report. 
The whole number of fractures of the clavicle during this period was 191. 2 

Lente also mentions a case, seen by himself, occasioned by the fall of 
a derrick upon the shoulder. The patient, twenty-four years old, was 
admitted into the New York Hospital in August, 1848. The left clavicle 
was broken at about its middle, and a large wound in the integuments 
communicated with the fracture. The fragments united firmly in about 
six weeks, after several pieces of bone had been discharged from the 
wound. 3 

A double fracture, or a simultaneous fracture occurring in both clavi- 
cles, seldom occurs. I have recorded two cases {four fractures, three 
of which are incomplete), both occurring in young boys. 4 Dr. Burr, of 
Binghamton, X. V.. has reported a case which occurred in ;i man aboul 

1 Loi 

i \. y \[. : ] . M msh 16, L861. 
V Jo in of Med , July, I860 
♦ Rep. on Dei. afl I' I 6 10. 



216 



FRACTURES OF THE CLAVICLE. 



50 years old. 1 To these M. Polaillon has added 8 others gathered from 
various sources. 9 Malgaigne says it has only happened once in 2358 
,; the Bote! Dieu, and he can recollect only five other examples. 
And of L58 cases of broken clavicles reported from the New York Hos- 
pital, it is Btated to have occurred in only four. 

Symptoms. — In all cases of complete fracture with displacement, no 
difficulty will be experienced in deciding upon the nature of the injury. 

The patient is t«»und generally leaning toward the injured side, whilst 
the opposite hand sustains the elbow of the same side, to prevent its 
dragging downwards. 

The Bhoulder falls downwards, forwards, and inwards; whilst, at the 

same time, the line of the bone is 
Fie. interrupted by the sharp and pro- 

jecting point of the sternal frag- 
ment. 

If the fracture is the result of a 
direct blow, a swelling and dis- 
coloration may be seen at the seat 
of fracture ; but if it is the result 
of a counter-stroke, we must look 
to the top or point of the shoulder 
for the signs of a contusion. 

The patient also experiences 
pain when an attempt is made to 
raise the arm at a right angle with 
the body, and especially in at- 
tempting to carry the arm across 
the body, by which the ends of the 
broken clavicle are driven into the 
flesh. In two cases (Cases 19 and 
50 of my Report on Deformities) 
of oblique fracture, accompanied 
with displacement, occurring in the middle third of the bone, I have par- 
ticularly noticed that the patients could easily lift the hands to the head, 
and in one of these cases the patient, a boy fourteen years old, raised his 
arm perpendicularly over his head. Such exceptions are not very un- 
common. 

Crepitus can be detected sometimes by simply pressing down the 
Bternal fragments, hut it is almost always present when we draw the 
shoulders forcibly hack, bo as to bring the broken fragments into more 
perfect conl 

If there i- no displacement, still crepitus may generally be discovered 
3 asping the hone between the thumb and fingers, and moving it 
gently up and down, or by Blight pressure upon the point of fracture. 

When the fracture occurs close to the acromial extremity, external to 
the coraco-clavicular ligaments, quite frequently there is no perceptible 
or marked displacement, and its diagnosis will require, therefore, more 
care and attention on the part of the surgeon. 

B lit, M : !:• . Kay 0, 1*82. 

Polaillon, Die. Enc. •:• - Sci. Med., t. 17. p. 691. 




Complete Fracture. — Oblique: at junction of 
outer and middle thirds. (From nature.) 



FRACTURES OF THE CLAVICLE. 



217 



Prognosis in this fracture deserves especial attention. In no other 
bone, except the femur, does a shortening so uniformly result. Of 
seventy-two complete fractures only sixteen united without shortening : 
and of twenty-seven simple, oblique, complete fractures, which occurred 
at or near the outer end of the middle third, only one united without 
shortening (Case 46 of my Report), and in this case the patient was 
but fifteen years old, and the fragments were never much displaced ; 
nor can I say that the treatment — a board across the back, after the 
manner of Keckerley — had anything to do with the result. Six cases 
of complete transverse fracture, occurring at the same point, united 
without shortening. 

The shortening, after the union is consummated, varies from one- 
quarter of an inch to one inch or more : and the fragments are almost 
always, especially wdien the fracture is through the middle third, found 
lying in the position in which we have described them to be at the first ; 
the outer end of the inner fragment being above, and often a little in 
front of, the outer : sometimes, especially in lean persons, and when the 
fractures are very oblique, presenting a sharp and unseemly projection. 

The greatest amount of shortening is generally found in those fractures 
which occur through the middle third, or, as Dawson has correctly said, 
between the rhomboid and coraco- 

clavicular ligaments. 1 In fractures FlG - " )1 - 

near the sternal end. within the region 
occupied by the rhomboid ligament, 
there is usually very little permanent 
displacement. The same is true when 
the fracture is at the acromial end, 
and between the fasciculi of the 
coraco-clavicular ligaments, as the ob- 
servations of Robert Smith, already 
quoted, have sufficiently established: 
but if the fracture is beyond these 
ligaments, near the acromial end. the 
final displacement and deformity may 
be very great. 

The presence of a small amount 
of ensheathing callus soon after the 
cure is completed, sometime.- increases 
the deformity. It is rarely seen to 
encircle the bone completely, and oc- 
casionally it appears to be most abundant in the direction of the salient 
points of the fracture, thai is, above and belon ; so that, unless the 
examination is made with care, the projecting points of callus which 
remain, sometimes after many your-, may be easily mistaken for an 
intercepted fragment turned at right angles to the axis of the hone. 

Robert Smith has observed, also, that in cases of fracture externa] to 
the conoid ligament, osseous matter is freely formed upon the under 




('..in minuted Fracture. — inked. 
(From nature.) 



i W. W. Dav - M.D.. P 
nati. Jan. 5, 



218 FRACTURES OF THE CLAVICLE. 

Bur&oe of each fragment, but there is seldom any deposited upon the 
upper surface of either. These osseous growths, occupying the situation 
of the coraco-clai icular ligaments, frequently prolong themselves as far as 
the ooracoid process, and in some cases to the notch of the scapula. Still 
less frequently these osteophytes become fused with the coracoid process, 
and a true anchylosis exists. 

In comminuted fractures the intercepted fragments generally fall off 
from the line of the other fragments, and cannot easily be restored. 

The clavicle, being a spongy and vascular bone, usually unites with 
greal rapidity, generally within twenty days. In the fourth example of 
transverse fracture already mentioned as having been seen by me, the 
union seemed to be tolerably firm in seven days. Wallace reports one 
case from the Pennsylvania Hospital, which was cured in eight days, and 
another in nine days. 1 Velpeau says the clavicle will unite in from 
fifteen to twenty-five days; Benjamin Bell in fourteen; Stephen Smith 
has seen it firm in fifteen days. 

Whatever may be the degree of displacement, or the condition of the 
system, unless in a case of gunshot fracture, it is very seldom that it 
refuses to unite altogether, or that the union is ligamentous. In Muhlen- 
berg's tables of 656 eases of delayed and non-union of long bones, there 
is hut one example of non-union of the clavicle. And in the few cases 
found upon record of a ligamentous union, the functions of the arm do 
not seem to have suffered any serious ultimate injury, as the following 
example will illustrate: 

Edmund Nugent, a stout Irish laborer, twenty-five years old, was 
received into the Buffalo Hospital of the Sisters of Charity, in March, 
1854. Several years before, he fell from a horse, and broke his left 
clavicle, at the outer end of the middle third. This was near Cork, in 
Ireland; and. without eonsulting any surgeon or "handy man," he con- 
tin ued at work, holding the tail of the plough, nor from that day forwards 
did he employ a surgeon, or dress his arm, or cease from his work. 

The clavicle presented the same deformity which many other similar 
fractures present after what is usually termed successful treatment, except 
thai it \\;i> not united by bone. The outer end of the inner fragment 
rode upon the inner end of the outer fragment half an inch. The liga- 
ment uniting the two extremities was so long and firm that it could 
ho distinctly felt, and the fragments moved upon each other with great 
freedom. 

In order that we might determine the amount of injury which he had 
suffered from the ligamentous union, we directed him to lift weights 
placed on ;i table before him. while he was seated upon a chair. We 
ascertained from this experiment that with his left arm he could lift as 
much, within three ounces, as he could with his right, and he was not 
himself conscious of any difference. The .muscles of the left arm seemed 
;i< well developed ;•- those of the right. 

In May, 1868, I found in the (narity Hospital, Blackwell's Island, 
in the person of A. Bragg, aet. thirty-four, a fracture of the left clavicle, 
which had united only by ligament. The fracture had occurred, when 

1 Am. Journ. Med. Sci., vol. xvi. p. 115. 



FRACTURES OF THE CLAVICLE. 219 

be was twenty years old. at about tbe junction of tbe outer fourth with 
the inner three-fourths. No surgeon was employed, and no treatment 
had ever been adopted. The ligament was quite long, and the fragments 
moved freely upon each other, yet the arm was nearly as strong and as 
useful as before. 

Chelius also refers to two cases mentioned by Gurdy and Yelpeau, in 
which, although an artificial joint remained, the use of the limb was but 
little impaired. 1 

In a case of compound and comminuted gunshot fracture reported by 
Ayres. of New York, the recovery was remarkable. The man was sixty- 
two years old, and in excellent health, when the injury was received. 
The clavicle was so extensively comminuted that before the wound closed 
over one-third of the bone had escaped, and yet at the end of one year 
from the time of the accident the shoulder was perfectly symmetrical 
with its fellow, without drooping or falling forwards. Dr. Ayres thinks 
that all of the clavicle which was lost had been reproduced. 

A partial paralysis, with atrophy of the muscles of the arm. accom- 
panied, also, with more or less rigidity and contraction of the muscles 
both of the arm and forearm, is, according to my observation, a more 
frequent result of these fractures. 

Mr. Earle has recorded a case of comminuted fracture of the clavicle, 
in which the nerves converging to form the axillary plexus were so much 
injured that paralysis of the arm ensued: and it was noticed as an inter- 
esting fact, that the patient could not afterwards put her hand into even 
moderately warm water without the effects of a scald being produced, 
characterized by vesications, redness, etc. 2 

Desault saw a case at Hotel Dieu, in which, although the clavicle was 
not broken, the force of the blow upon the clavicle was sufficient to pro- 
duce a severe concussion of the brachial plexus, and paralysis of the ami. 
A timber had fallen from a building, striking upon the external pari of 
the left clavicle. A considerable wound, followed by swelling, pointed 
out the place on which the blow had been received. No apparatus was 
applied, and on the third day a numbness and partial loss of the power 
of motion occurred in the arm of the affected side. Soon afterward an 
insensibility came on. and by the seventh day the paralysis of the arm 
was complete. It was not until after a tedious treatment thai the limb 
recovered in part its original strength. 3 

In Case 23 of my report to the American Medical Association, which 
was followed by paralysis of the opposite arm, and spinal curvature, these 
results were probably due to some injury of the hack received at the 
time of the accident ; hut one cannot avoid a suspicion that the apparatus, 
Brasdor's jacket, contributed somewhat to the unfortunate result. No 
axillary pad was employed, hut the straps over ouch shoulder were 
buckled so tight that he was compelled to incline his head constantly to 

the right side. lie wa£ unable to lie down, and could only incline in a 

half-sitting posture. This treatment \\;i- continued four weeks; and two 
month- after it- removal the paralysis and spinal distortion commenced. 

1 Chelius, .\ 

Cooper's Pirel Lines, fourth Amer. <•<!.. vol. ii. p 828. 
f) saull on True and Disloc., Amer ed., j>. 1 t. 1806. 



220 FRACTURES OF THE CLAVICLE. 

In Case 88, also, of the same report, a comminuted fracture, paralysis 
with contraction of the muscles extending to the wrist and fingers existed, 
Km whether it was due to the severity of the original injury or to the 
treatment, could not be satisfactorily ascertained. 

Gibson relates a remarkable instance of this kind. A young man was 
Btruck on the clavicle by the falling limb of a tree, breaking it into 
Dumerous pieces, and bruising the parts so severely as to give rise to 
violent inflammation. "The fragments had been driven behind and 
beneath the level of the first rib, and so compressed the plexus of nerves 
as to wedge them into each other, and by the subsequent inflammation to 
blend them inseparably together. Complete paralysis and atrophy of the 
whole arm ensued, and the patient's object in visiting Philadelphia was 
to Bubmit to an operation, in hopes of elevating the clavicle to its natural 
height, and taking off pressure from the nerves." Dr. Gibson, however, 
did n<»t believe that the prospect of success was sufficient to warrant the 
operation, and the young man was sent home. 1 

It will not do to deny, therefore, the possibility of a paralysis as re- 
Bulting from a concussion of the axillary nerves, produced by a blow 
upon the clavicle, nor of a paralysis resulting from a direct injury inflicted 
by the points of the fragments upon this plexus in certain very badly 
comminuted fractures; but it is certain that these conditions will not 
satisfactorily explain all of the examples in which paralysis has followed 
simple fractures. In some cases it is no doubt due rather to the injudi- 
cious mode of using an axillary pad, by means of which the arm is con- 
verted into a powerful lever, and thus the brachial nerves are made to 
Buffer from compression along the inner side of the arm itself. In short, 
it must he confessed that it is sometimes due to the treatment alone, and 
not to the original injury. 

Parker, of New York, in a note to the edition of S. Cooper's Surgery, 
just quoted, declares that he has seen one patient who had lost the use 
of his arm from the pressure upon the nerves by the wedge-shaped pad, 
over which the limb was confined, in order to pry the shoulder outwards. 
Stephen Smith mentions a case of partial paralysis from the same cause. 2 

A similar case has come under my own observation. A lady, aged 
fifty-one years, was thrown from her carriage, breaking the right clavicle 
obliquely at the outer end of the middle third. During the first three 
weeks the arm was dressed with Fox's apparatus, which was at no time 
particularly painful. She was then placed under the care of another 
Burgeon, who, finding the fragments overlapped, applied very firmly a 
figure-of-8 bandage, with an axillary pad, securing the arm snugly to the 
v 'd<- of the body; hoping by these means to restore the fragments to 
then- places 'flic pain which followed was excessive, and, notwithstanding 
the free use of anodynes, it became so insupportable that at the end of 
fourteen hour- the dressings were removed by another surgeon, and Fox's 
apparatus again substituted. These were also applied much more tightly 
than ;ir first, and during the four weeks longer that they remained on, 
repeated attempts were made to reduce the fragments. 

1 Gibson, ■>]>. cit., 6th ed., vol. i. p. 271. 

Smith, X. u York Journ. of Medicine, May, 1857. 



FRACTURES OF THE CLAVICLE. 221 

Forty-eight days after the accident, she consulted me. The clavicle 
was then united, and overlapped half an inch. The whole arm was 
swollen, painful, and very tender, with total inability to move it. 

I removed all the dressings, and, during the time she remained under 
my care, in a private room at the hospital, there was a gradual improve- 
ment in the condition of her arm, in respect to swelling and tenderness, 
but the paralysis did not much abate. 

Erichsen thinks he has seen one case of comminuted fracture, produced 
by a direct blow, in which the subclavian vein was ruptured ; great ex- 
travasation of blood resulted, and the arm was threatened with gangrene. 
The patient having recovered, however, the diagnosis could not be deter- 
mined by actual dissection. 1 

M. Alaunoury, of Chartres, met with a similar case, in which, while 
attempting to tie the vein, the patient died in consequence of the admis- 
sion of air. 2 

J. W. Ogle has reported a case of wound of the internal jugular caused 
by a fragment of a broken clavicle. 3 

Dupuytren stated in a clinical lecture in 1831, that he had seen two 
examples of aneurism consequent upon fracture of the clavicle. Follin 
says, that Sir Robert Peel having been thrown from his horse, had his 
left clavicle broken, and death ensued, in consequence, it was believed, of 
a traumatic aneurism resulting from a wound of an arterial vessel. 4 
Blandin has also reported an example of supposed laceration of the sub- 
acromial artery in consequence of a direct blow. 5 

"M. More, reported to the Surgical Society, in 1876, a case of fracture 
of the clavicle, in which M. Verneuil and the majority of the members 
admitted the existence of a partial rupture of the subclavian artery. 
An old man had his clavicle broken in consequence of direct violence. 
The apparatus (bandage and axillary pad) was only applied on the third 
(lav : on the same evening pains and formications occurred in the hand, 
which, the next day, presented a bluish appearance in color ; in addi- 
tion, no pulsations in the radial or ulnar arteries could be felt. In view 
of these accidents, the apparatus, already loose, was removed. It took 
two months for the limb to regain its normal strength and appearance ; 
but the pulsations in the vessels did not return until after the lapse of 
eight months. Indeed, this case is not absolutely conclusive, and, not- 
withstanding the great authority of the surgeons who admitted the rup- 
ture of an artery, it is fair to ask if the pressure produced by the axillary 
pad was not, as in the cases reported above, the real cause of all these 
accident-." 

To these judicious comment> of M. Poinsol in reference to the case of 
M. More, I wish to add my opinion, thai there is ,L r "««l reason for believ- 
ing, if a vessel were torn, it was done by the surgeon in bis attempts 
to restore the fracture to place: and that if it was Qol torn, the riolenl 

i Erichsen, - rg Amer. <■<! . p. 205. 
Maunourj . I' s Med., A i 
. Brit. Bled. Journ., July 26, 
in. Path. Ext., i 2d, p. B49. 
5 Jacquemier, ti. Paris, 1844, p. 86. 

• m.. ... i:. . ,:■ . 8, . Med., t. 1". p. 286. Poinsot. 



222 FRACTURES OF THE CLAVICLE. 

ami injudicious efforts of the surgeon to maintain it in place by an 
axillary pad. bandages, ete. r might explain the obliteration of the arterial 
circulation. The lesson is not, in my opinion, to be overlooked by those 
who bo assiduously attempt, by similar means, to accomplish what, in 
most cases, is impossible. 

Fracture of the clavicle may also be complicated with a wound of the 
lung and with extensive emphysema. M. Polaillon has published three 
cases of this kind taken from Vigaroux, Velpeau et Huguier. Very 
recently, M. Gribier de Savigny reported a case of fracture of the clavicle 
in which the external fragment had perforated the lung. Considerable 
emphysema supervened, and the patient recovered almost without treat- 
ment ; but a pseudarthrosis remained. 1 

Since among surgeons some difference of opinion seems to exist as to 
the practicability of overcoming the displacement in certain fractures of 
the clavicle, it is proper that I should defend the accuracy of my own 
observations by a reference to the observations of others. 

In nine of eleven cases reported by Stephen Smith, one of the sur- 
L r <<)iis at Bellevue Hospital, New York, more or less deformity remained 
after the cure was completed. In the two remaining cases the actual 
results are unknown. 2 

( nelius remarks : " Setting of this fracture is easy, yet only in very 
rare cases is the cure possible without any deformity." . ... " It is 
considered, also, that the close union of the fracture of the collar-bone 
depends less on the apparatus than on the position and direction of the 
fracture (therefore, in spite of the most careful application of this appa- 
ratus, some deformity often remains)." 3 

Velpeau, in a lecture given in 1846, and published in the G-azette 
des ffopitaux, declares that with all the bandages imaginable, in the 
of an oblique fracture at the junction of the outer third with the 
inner two-thirds, we cannot prevent deformity. 

Yidal observes: "Fracture of the clavicle is almost always followed 
by deformity, whatever may be the perfection of the apparatus and the 
• are of the surgeon." 4 

• Hippocrates has observed that some degree of deformity almost 
always accompanies the reunion of a fractured clavicle; all writers 
since bis time have made the same remark; experience has confirmed 
the truth of it." 5 

Turner remarks as follows: "As to the reduction of this fracture, it 
must be owned the same is often easier replaced than retained in its 
place after it is reduced; for its office being principally to keep the 
head of the scapula, or shoulder, to which, at one end, it is articulate, 
from approaching too near, or falling in upon the sternum, or breast- 
bone, it happens that, on every motion of the arm, unless great care be 

1 Polaillon, Diet Encyc. deeSci. Med., t. 17, p. 695. French ed. of this treatise, 
).. 220 Qflot. 

* Fort Jonra. Med . B£ay, L857, p. 382. 

of Surgery. By J. M. Ohelius, of Heidelberg, with notes bv South. 
\mkt. ed., v-,1. i. pp. 608, 605 

iria ed., vol. ii. p. 105. 
on Fractures and Luxations. By J. P. Desault. Edited by Xav. Bichat. 
:md translated by Charles Caldwell, M.D. Philadelphia, 1805, p. 9. 



FRACTUKES OF THE CLAVICLE. 223 

taken, the clavicle therewith rising and sinking, the fractured parts are 
apt to be distorted thereby. Besides, even in the common respiration, 
the costse and sternum aforesaid, where the other end of this bone is 
adnected. together with the motion of the diaphragm, rising and falling, 
especially if the same be extraordinary, as in coughing and sneezing, 
are able to undo your work, not to mention the situation thereof, less 
capable of being so well secured by bandage as many others. All which, 
duly considered, it is no wonder that upon many of these accidents, 
although great care has been taken, these bones are sometimes found to 
ride, and a protuberance is left behind, to the great regret particularly 
of the female sex, whose necks lie more exposed, and where no small 
grace or comeliness is usually placed/' 1 

Says Johannis de Gorter : %i Restituiter facile tractis humeris a min- 
istro posterius, dum simul suo genu locato ad spinam dorsi, dorsum sus- 
tentet minister, nam tunc chirurgus folis digitis claviculam fractam re- 
ponere potest. Ditficilius autem in reposita sede retinetur, sed loca 
cava supra et infra claviculam spleniis implenda." 2 

Says Heister. writing only a little later : " The reduction of a broken 
clavicle is not very hard to be effected, especially when the fracture is 
transverse : nor is it unusual for the humerus, with the fragment of the 
clavicle, to be so far distorted as not to be easily replaced with the fingers ; 
but the difficulty is much greater to keep the bone in its place when the 
fracture is once reduced, especially if the bone was broken obliquely. " z 

Amesbury. after having exposed the inefficaey of all previous modes 
of dressing, and especially of the figure-of-8 bandage, Desault's, Boyer's, 
and an apparatus recommended by Sir Astley Cooper, proceeds to describe 
his own apparatus and to affirm its excellence. It is, however, not much 
unlike a multitude of others, and is liable to the same objections. 4 

M. Mayor, of Lausanne, thinks that up to this day no successful mode 
of treatment has been devised. " Here everything appears as yet so 
little determined, that each day sees some new propositions and different 
procedures," etc. He believes, however, that in his simple handkerchief 
bandage, with straps across each shoulder, the indications are most fully 
accomplished and the most successful results are obtained. If, however, 
it were to be treated ivithout apparatus, the horizontal position, lying 
upon the back, would, in the end, make the most perfect unions. 5 

Says M. Malgaigne : " The prognosis, considering the trivial character 
of this fracture, is sufficiently difficult. For, little as may be the dis- 
placement, the surgeon ought not to promise ;i reunion without deformity ; 
and certain successful results, proclaimed from time to time, betray, on 
the part of those who relate them, the most extravagant exaggerations." 4 

M. Nelaton having spoken of the various plane which have been sug- 

1 The Art of Surgery, by Daniel Turner, vol. ii. p. 266. London ed., 1742. 

2 Johannis de Qorter ; Chirur<_ r i;t I: mi Batavorum, 1712. 

3 Heister'a .Sunrery, vol. i. p. 184. LoncL ed., 1768. 

4 Treatment of Fracti ; i Amesbury, vol. ii. p. oL'7. London ed., 1881. 

5 Nouveau Systeme de Deligatiou Chirurgicale, par Hathiae Mayor, <l<- Lausanne, 
p. 384, etc. (also Atlas, plate 8, figure 28). Paris ed., 

6 Traits dec itions, par J. K. Vfalgaigne, tome premier, p 
Paris ed.. 1847 



FBACTUBES OF THE CLAVICLE. 

I to retain this bone in place, and of their inefficiency, comes at last 
to speak of the handkerchief bandage of M. Major, and remarks: 

" This apparel la very simple: but neither will it remedy the over- 
lapping." .... " Of all the apparels which we have passed in review, 
there is, then, not one which fills completely the three indications usually 
present in the fracture of a clavicle. None of them oppose the displace- 
ment : they have no effect, with whatever care they may be applied, but 
to maintain immobility in the limb. We think, then, that it is useless 
to fatigue the patient with an apparatus annoying, and, perhaps, even 
painful : a simple sling, secured upon the sound shoulder, will be suffi- 
ciently severe. Nevertheless, as this does not assure so complete iinmo- 
bility as the bandage of M. Mayor, it is to this that we think the prefer- 
ence ought be given in all cases of fractures of the clavicle, whether 
accompanied with displacement or not, whether they occupy the middle 
or the external part of the clavicle. If the fracture presents no dis- 
placement, we shall obtain a cure which will leave nothing to be desired. 
If there is a tendency to displacement, the consolidation will be effected 
with a deformity more or less marked ; but since this deformity is in- 
evitable, at least with adults, whatever may be the apparel which we 
employ, it is evident that the apparatus which causes the least constraint 
ought t<» have the preference. We may remark, farther, that this union 
with deformity in no wise impairs the free exercise of all the movements 
of the members." 1 

" The venerable gentleman who stands at the head of American sur- 
gery, and whose manipulations with the roller approach very nearly to 
the limits of perfection, informed us, in 1824, that he had never seen a 
of fractured clavicle cured by any apparatus, without obvious de- 
formity." 

I need imr Bay that the ''venerable gentleman" to whom Dr. Coates 
refers in this passage was the late Dr. Physick, of Philadelphia. 

Dr. Gross says that, according to his experience, "fractures of the 
clavicle are seldom cured without more or less deformity, whatever pains 
may be taken to prevent it." 3 

Among the late German authors, Eoser speaks as follows: "The treat- 
ment <»f fractures of the clavicle is, after all that has been said, very 
imperfect: and it is very often the case that, after a most careful treat- 
ment, some deformity will remain, such as protrusion of the inner frag- 
ment, crossing of the fragments, and consequent shortening." 4 

- Bryant, in hi- excellent Treatise on Surgery, " Deformity almost 
always exists in spite of treatment."" 

Treatment — If evidence were needed beyond that which has been 
famished, of the difficulty of bringing to a successful issue the treatment 
of this fracture, it might be supplied, one would think, by a reference 

1 Elements de Pathologie Chriurgicale, par A. Xelaton. tome premier, p. 720. 
1.. 1844. 

I. Journ., vol. xviii. p. 62, old series. It is probable 
that Dr. Physick 1 L to complete and oblique fractures of the middle third, 

or that Dr. I • • has • ■■_ •• :. •: • precise language employed on this occasion. 
a ery, vol. i. p. 964, I B72. 
' ^ v Chirurgie, 6 Aufl., Tubingen, 1872. 

Bryant, Pract! 9 _■ L872, p. 927. 



FRACTURES OF THE CLAVICLE. 225 

merely to the immense number of contrivances which have been at one 
time and another recommended. 

A catalogue of the names only of the men who have, upon this single 
point, exercised their ingenuity, would be formidable, nor would it pre- 
sent any mean array of talent and of practical skill. 

All these surgeons, however, have admitted the same indications of 
treatment, viz.. that in order to a complete restoration of the outer frag- 
ment, which alone is supposed to be much displaced, we are to carry the 
shoulder upwards, outwards, and backwards. But as to the means by 
which these indications can be most easily, if at all, accomplished, the 
widest differences of opinion have prevailed: and. in the debate, it may 
be seen that whilst, on the one hand, no invention has wanted for both 
advocates and admirers, on the other hand, no method has escaped its 
equivalent of censure. 

Hippocrates. Celsus. Dupuytren. Flaubert. Lizars, Pelletan, and others, 
directed the patients to lie upon their backs, with little or no apparatus. 
S. I ><>per and Dorsey also recommend that the patients should be confined 
in this position during most of the treatment: and from the account 
given by Dr. Lente, it will be understood that a similar plan was at one 
time adopted in the ^Sew York City Hospital. "But this result," speak- 
ing of angular deformity, not overlapping of the fragments, "rarely 
happens when the patient lias strictly followed the directions of the sur- 
. as to position especially, for it is by position, more than by any 
other remedial means, that a good result is to be effected. " 

Nearly the same method we find recommended by Alfred Post, in 
l v 4<». then one of the surgeons of that hospital; the arm being merely 
kept in a sling and bound to the Bide, with the patient lying upon his 
back. Dr. Post mentions a cast- treated in this manner, which termi- 
nated with very little deformity: 1 and I have myself treated many cases 
by this plan, with more than average success. 

Dr. Edward Hartshorne, of Philadelphia, has published, in the second 
volume of the Pennsylvania Hospital Reports, 1869, a very ingenious 
argument in favor of the supine position, in which he seems to have 
demonstrated that the special efficacy of this plan depends upon the 
pressure made against the angle of the scapula. In order to accomplish 
this, and to place the scapula in the position most favorable for the 
reduction of the clavicle, the back should rest upon a broad, firm, and 
unyielding mattress, and not upon a pillow between the shoulders, which 
latter has the effect rather to defeat than to promote the indication: the 
head should be slightly raised so as to relax the sternocleidomastoid 
muscle- and somewhat extend the trapezius; the arm and forearm of the 
injured side should be flexed, resting across the chest, with the hand 
reaching over the sound shoulder, as recommended by Velpeau in tin- 
use of his dextrine apparatus, or it should be placed at right angles with 
the body, a- recommended by Dupuytren. Bryant, of London, recom- 
mends essentially the Bame method. 

It is scarcely necessary to say that the absolute immobility required 
by the posture treatment hum always limit it- application, and render 

1 >~. V. Journ. of Med., vol. ii. p. 



226 



I KATTURES OF THE CLAVICLE. 



its genera] employment impossible. Dr. J. A. Packard, of Philadelphia, 
regards the scapula, also, as the bone upon which the restoration of the 
clavicle chiefly depends; and he finds in the serratus magnus the especial 
obstacle to this restoration. 1 

Dr. Eve, of Nashville, Tenn., and Dr. Eastman, of Broome County, 
N. Y.. bave also employed this method successfully; 2 whilst Malgaigne 
declares it to be the mosl reliable means of obtaining an exact union. 

Albucasis, Lanfranc, Guy de Chauliac, Petit, Parr, Syme, Skey, 
Brunninghansen, and very many others, especially among the English, 
have preferred, in order to carry the shoulders back, a figure-of-8 ; whilst 
Desault, Colles, South, Bryant, and Samuel Cooper have represented 
this bandage as useless, annoying, and mischievous. 

Heister, Ohelius, Miller, Breffield, Keckerly, 3 Coleman, 4 Hunton, 5 
prefer, for this purpose, some form of back-splint, extending from acro- 
mion to acromion, against which the 
F "' ~ y2 - shoulders may be properly secured. 

Parker says that splints of this kind, 
with a figure-of-8 bandage, are "better 
than all the apparatus ever invented," 
whilst Mr. South gives his testimony in 
relation to all dressings of this sort as 
follows : " I do not like any of the appa- 
ratus in which the shoulders are drawn 
back by bandages, as these invariably 
annoy the patient, often cause excoria- 
tion, and are never kept long in place, 
the person continually wriggling them 
off to relieve himself of the pressure." 

Fox, 6 Brown, 7 Desault, and others 
bring the elbow a little forwards, and 
then lift the shoulder upwards and back- 
Figure-of-8. wards. Wattman and Lonsdale carry 

the elbow still farther forwards, so as 
to lay the hand across the opposite shoulder; whilst Guillou carries the 
hand and forearm behind the patient, and then proceeds to lift the 
shoulder to its place. Moore, also, recommends that the elbow shall be 
carried back. 

Thus Desault, Fox. and Wattman accomplish the indication to carry 
the shoulder back, by lifting the humerus, with the elbow in front of the 
body : whilst GuUlou and Moore accomplish the same indication by lift- 
ing the humerus when the elbow is a little behind the body. Chelius 

Packard, \<w York Journ. of Med., 1867. 
B -• Med. and Surg. Journ., vol. h-i. p. 468. 

kerly, Ajner. Journ. Med. Bci., vol. xv. p. 115; also, my Report on Deformi- 
Eter Fractures, in Trans, of Amer. Med. Assoc , vol. viii. p. 440. 

man, New York Journ. Med., second series, vol. iii. p. 274, from New Jersey 
Med. Rep. ^ ' J 

d, ibid. : also, NTew Jersey Med. Rep., vol. v. p. 146. 
icticftl Surgery, Amer. ed\, p. 47. 
B \ a, Sargent'e Minor Surgery, p. 132. 




FRACTURES OF THE CLAVICLE. I'll 

also says : " The elbow, as far as possible, is to be laid backwards on 
the body." 

Sargent, who believes that with Fox's apparatus " the occurrence of 
deformity is the exception," and not the rule, and prefers it to all others, 
has treated three cases by Gruillou's method, and is perfectly satisfied 
with its operation. Hollingsworth. of Philadelphia, has also treated one 
case successfully by Gruillou's method, and adds his testimony in its 
favor. Several surgeons think they have obtained equal success with 
Moore's apparatus. 

But how shall we explain these equal results from opposite modes of 
treatment ? Is the indication to carry the shoulders back, which Fox 
sought to accomplish by pressing the elbow upwards and backwards, as 
easily attained by pressing the elbow upwards and forwards ? Or are 
we not compelled to infer that there has been some mistake as to the 
precise amount of good accomplished by the apparatus in either case ? 
Moreover, Coates, 1 Keal, and others instruct us that the only safe and 
proper position for the humerus is in a line with the side of the body, and 
that it must neither be carried forwards nor backwards. 

Paulus ^Egineta, Boyer. Desault, Pecceti, Liston, Fergusson, Samuel 
Cooper. Erichsen, Miller. Skey, Levis, Dorsey, 2 Gibson, 3 Fox, H. H. 
Smith. 4 Xorris. 5 Sargent. Eastman, 6 recommend an axillary pad: whilst 
Richerand, Velpeau. Dupuytren, Benjamin Bell. Syme, Moore, deny its 
utility, or affirm its danger. Dr. Parker has seen one patient in whom 
paralysis of the arm resulted from the pressure upon the brachial nerves, 
in the attempt " to pry the shoulder out; " and I have myself recorded 
another. 

Cabot, of Boston, Massachusetts, has recommended a mould of gutta 
percha laid over the front and top of the chest. 7 

Desault's plan, which took its origin, a- Velpeau thinks, in the spica 
of Glaucius. under various modifications, is recommended by Delpeeh. 
Cruveilhier. Lasere. Flamant. Samuel Cooper, Fergusson, Liston, Cut- 
ler. Physick, Dorsey. Coates. and Gibson: whilst by Velpeau, Syme, 
Colles, Chelius, Samuel Cooper, and Parker, it is regarded as inefficient 
and troublesome. Says Mr. Cooper: "In this country, many surgeons 
prefer Desault's bandages: but I do not regard them as meeting the 
indications, and consider them worse than use) 

The dextrine bandages, or apparatus immobile, of Blandin, Velpeau, 
ami others, constitute only another form of the bandage dressing of De- 
sault. In this connection it ought to be noticed that Velpeau does not 
regard the employment of this apparatus, or of any other demanding 
great restraint, as imperative. In his great work on anatomy, referring 
to the fact that when the bone is broken and overlapped, the patienl is 
still able, in many cases, to move the arm freely, he remarks: " Do not 

1 Coates, Am. Journ. Med. 8ci., vol rviii. p. 62. 

2 Dorsey, Elements of Burgery, vol. i. p. Li 

3 Gibson! Inatitut v - vol. L p. 271. 

4 H. H. Smith, Practi 

6 Eastman. Apparatus ed Clavicle, by Paul Eastman, Aurora, m. ; 

and Surg. Journ.. vol. rxiii. j>. 170. 

7 Cabol B rt. M 9urg. Journ., vol. lii. p 



228 



FRACTURES OF THE CLAVICLE. 



these cases give support to the opinion of those who admit that fractures 
of the clavicle do DOl actually require any other apparatus than the 
simple supporting bandage?" "It is necessary to observe," he adds, 
" thai by thus acting we do not prevent an overlapping," 1 etc. 

According to Flower and Hulke, authors of the article on " Injuries 
of the Opper Extremities" in the last edition of Holmes's Surgery, in 
mosi of the hospitals in London the surgeons employ a moderate-sized 
pad in the axilla, and then secure the arm to the body with a broad 
calico roller, some of the turns of which are made to pass beneath the 
elbow and over the opposite shoulder. Some of the surgeons advance 
the elbow, others carry it back, but a majority permit it to hang per- 
pendicularly beside the body. As will be hereafter seen, this plan is 
essentially the same as that adopted by myself. 

Professor E. M. Moore, of Rochester, in a paper read .before the New 
York State Medical Society in 1871, has called attention to what he 
terms the "Figure-of-8 from the elbow," by which he proposes to render 
tense the clavicular fibres of the pectoralis major, and at the same time 



Fig. 53 




Moore'.- tpparatus. Buck view. 



Moore's apparatus. Front view. 



draw the Bcapula backwards toward the spine. He is thus able, he 
affirms, to overcome the action of the sterno-cleido-mastoid, which lifts 
the BternaJ fragment; and to draw the acromial fragment outwards and 
upwards. 

These ends are accomplished by placing the extremity of the middle 
finger of the broken arm upon the ensiform cartilage, with the forearm 
and elbow pinned hack and against the body. In order to secure the 
arm in this position, "I use," says Dr. Moore, "a shawl or piece of 

1 Velpeau, Anatomy, Amer. ed., vol i. p. 242. 






FRACTURES OF THE CLAVICLE. 



229 



cotton cloth, which, when folded like a cravat, eight inches in breadth at 
the centre, should be about two yards long. Placing this at the centre 
across the palm of the surgeon, he seizes with his hand the elbow of the 
patient which corresponds with the broken clavicle. The two ends of 
the bandage hang to the floor. The one falling inwards toward the pa- 
tient is carried upwards, in front of the shoulder and over the hack, 
making a spiral movement in front of the shoulder. This is intrusted to 
an assistant. The outer end is then carried across the forearm, behind 
the back, over the opposite shoulder, and around the axilla. This meets 
the other end. which may be carried under the axilla and over the shoul- 
der of the opposite side, thus making the figure eight (8) turn, around the 
sound shoulder. This twist, it will be seen, makes also the figure eight 
(8) turn, around the elbow of the affected side. I therefore style the 
bandage 'The elbow figure eight (8).' " 

•• The forearm should be sustained by a sling which raises it to an 
acute angle in order that gravity may assist in moving the whole arm 
backwards. This is best done by a simple strip three or four inches 
wide, which may be pinned to the shawl at the shoulder, or by a sling 
across the opposite shoulder and behind the back. The former much to 
be preferred. Any tendency on the part of the shawl to slide from the 
shoulder may be arrested by a pin thrust at the crossing. The shawl at 
the elbow is kept in place by folding the upper part that fits the arm and 
securing it by a pin. This makes a sort of cup for the elbow."' 

The principle upon which this dressing is constructed appears to me 
sound : but hitherto, in the five or six cases in which it has been employed 
under my observation, it has failed to 
accomplish any more than is accom- 
plished by many other forms of dressing. 
It is especially liable to become disar- 
ranged, and to cause excoriations in the 
sound axilla; in this respect being quite 
as liable to criticism as the ordinary 
figure of eight. 

Dr. Lewis A. Sayre. of this city, lias 
for some time employed an apparatus 
for dressing broken clavicles, by which 
he proposes, also, to render tense the 
clavicular attachments of the pectoral is 
major, and thus secure more effectually 
the depression of the sternal fragment, 
while at the same time the shoulder is 
lifted and carried back. 

Two strips of adhesive plaster are pre- 
pared, each about three and a half inches 
wide, for an adult : one long enough to 
encircle, first the arm, and then the body 
completely : the other of sufficient length 
to reach from the sound shoulder, over 

the point of the elbow of the broken limb, and across the back obliquely 
to the point of starting. Maw's moleskin plaster, or some plaster equally 
strong, is to be preferred. 



Fig. 







230 



FRACTUKKS OF THE CLAVICLE. 



The first strip is looped around the arm just below the axillary margin, 
and pinned, or stitched, with the loop sufficiently open to avoid strangu- 
lation. The arm is then drawn downwards and backwards until the 
clavicular portioD of the pectoralis major is put sufficiently on the stretch 
to overcome the sterno-cleido-mastoid, and thus draw the sternal fragment 
of the clavicle down to its place. The strip of plaster is then carried 
completely around the body, and pinned or stitched to itself on the back. 

The Becond strip is then applied, commencing on the front of the 
shoulder of the sound side, thence it is carried over the top of the 
Bhoulder, diagonally across the back, under the elbow, diagonally across 



Fig. 56. 



Fig. 57. 





the front of the chest, to the point of starting, where it is secured by 
pins or thread. A longitudinal slit is made in the plaster, to receive the 
poinl of the elbow. 

Before laying the plaster across the elbow, an assistant must press 
the elbow well forwards and inwards, and it must be held firmly in this 
position until the dressing is completed. It will be now seen that the 
arm has been converted into a lever, whose fulcrum is the loop of 
adhesive plaster at the lower margin of the axilla; and upon this it is 
believed that in ;i great measure the efficiency of the apparatus depends. 

Certainly it no longer depends upon the position of the elbow, which 
was at firsl carried back in order to render tense the clavicular fibres of 
the pectoralis major, since, for the purpose of converting the humerus 
into a lever, the elbow is subsequently drawn forwards, and the clavicular 
fibres of the great pectoral are again relaxed. If, therefore, the appa- 
ratus has any advantages over other modes of treatment, it is solely 
by its action noon the humerus as a lever; but the fulcrum is too remote 
from the upper end of the humerus to act very efficiently. Great force 
has to be applied to secure this end, or at least so much force that, if 



FRACTURES OF THE CLAVICLE. 'IS L 

steadily maintained, it is pretty sure to cause excoriations of the arm 
where the fulcrum acts: or, as more often happens, it will speedily loosen, 
under the expansion and contraction of the chest in respiration, and 
thus cease to be efficient. Several cases of fractured clavicles, treated in 
Bellevue and St. Francis hospitals by this method, have come under my 
notice, some of which were dressed by Dr. Sayre himself, and the results 
have been no better than when my apparatus has been used, whilst they 
have in most cases caused much more discomfort. 

Dr. Satterthwaite has substituted Martin's elastic bandage for the 
adhesive plasters, and has devised a water bag to be used as an axillary 
pad, constructed in the form of a horse-shoe, which he says "has given 
entire satisfaction in the two instances in which it was applied.'" 1 From 
which I must infer that he is satisfied with a union accompanied with 
some overlapping of the fragments; a conclusion to which most other 
experienced surgeons have arrived. 

The sling, in some of its forms, is employed by Richerand, Huberthal, 
Colles. Miller, Fox, Stephen Smith, 2 II. H. Smith, Bartlett, 3 Levis, 4 
Dugas. 5 Benjamin Bell, Bransby Cooper, Earle, Chapman, Keal, and by 
a large majority of the English surgeons. 

Xo apparatus, perhaps, has been so generally employed, among 
American surgeons, as that form of the sling introduced by Dr. George 
Fox into the Pennsylvania Hospital in 1828. 

Sargent says of it: "Fractures of the clavicles, treated by this appa- 
ratus, arc daily dismissed from the Pennsylvania Hospital, and by sur- 
geons in private practice, cured without perceptible deformity." 

Norris, in a note to Liston's Practical Surgery, affirms that "the chief 
indications in the treatment of fracture of the clavicle are perfectly ful- 
filled by the use of this apparatus." 

H. H. Smith, in his Minor Surgery, declares that Fox's apparatus 
accomplishes "perfect cures" in very many cases, and that it is "a very 
rare thing for a simple case to go out of the house (Pennsylvania Hos- 
pital) with any other deformity save that which time cures, viz., the 
deposition of the provisional callus." He has also repeated substantially 
the same opinion in his larger work, entitled Practice of Surgery. 

Such testimony in favor of any dressing demands respectful attention; 
and I shall not be regarded as detracting from the respect due to these 
authorities when I express my belief that it is in deference to the distin- 
guished reputation of the surgeons who had during the preceding thirty 
years hud charge of the services in that hospital, and who have been so 
loud in its praise, that the use of this apparatus has, with as, become so 
general. I must be permitted, however, to express ;> doubt whether it 
has made deformities of the clavicle "the exception, instead of the rule," 
with us. I have used this dressing in the early years <>f my practice 

1 Thomas B. Satterthwaite, M.D., Medical Record, Sept. 27, 1879. 

Stephen Smith. Now York Journ. Med., vol. ii. 3d Beriea, p 884 May, 1867 
1 Bartlett. rny "Report on Defor.," etc., Appendix; also, Bost. Med. and Surg. 
Journ., vol. Ii. p. 104. For illustration, aee first edition. 

1 Levi.. H. II. Smith".- Practice of Surg., p. 865. Am. Journ. Med. Sci., April, 

5 Dugas, Report on Surgery. 



Ki: Ai'TI i; ES OF Til E CLAVICLE. 



quite often, bnl my Buccess has by no means been so flattering as has 
been the success of these gentlemen. 1 have seen others employ it. 
also, and with pretty much the same result. 

Pox's apparatus consists of a Bling, made of muslin cloth; a wedge- 
shaped axillary pad, made of muslin, also, stuffed, and half the length 
of the humerus; and of a stuffed collar. The axillary pad is not so 
thick or firm as Desault's pad, and for that reason is not likely to do 
harm. It is placed with its thickest end upwards, in the axilla corre- 
sponding to the broken clavicle, and se- 
cured in place by tapes attached to its 
upper end, and made fast to the stuffed 
collar upon the opposite shoulder. The 
sling is, in like manner, suspended from 
the stuffed collar. Finally, the hand is 
suspended over the front of the chest by 
a piece of muslin, looped under the wrist, 
and tied around the neck. No bandage 
is employed to confine the elbow to the 
body, and no effort is therefore made to 
convert the arm into a lever, and thus 
force the shoulder out. 

It will be understood that I am speaking 
of this dressing as it was employed some 
years ago, and when the gentlemen whom 
I have quoted spoke of it so approvingly. 
Since then it may have undergone many 
modifications, or it may have been laid 
aside altogether. 

It must be apparent to every practical 
surgeon that this apparatus could not 
answer "perfectly" all the indications of treatment, namely, to carry 
the Bhoulder up, out, and back, so that the clavicle would be made to 
unite without shortening or deformity. 

If. however, the writers intend only to say that no very serious, or 
very marked deformity usually ensues upon the plan of treatment, and 
in some cases none at all, then it will be proper to reply, that this 
amount of success may be attained by almost any form of dressing. It 
ha- been attained by myself with my own dressing, and with the dressing 
recommended by others. 

It will be further necessary to say that the absence or presence of a 
Btriking deformity, will depend very much upon the age of the patient, 
the character of the fracture — whether more or less oblique — upon the 
point at which the bone i< broken, and upon the condition of the patient. 
It will be generally more marked, other things being equal, in thin or 
muscular persons, than in those who are fat and of small and feeble 
muscle. If the overlapping of the fragments is in the plane of the sur- 
face of the integument, the deformity will be less apparent than if one 
fragment lies in front of the other. 

of the treatment of fractured clavicles by the wire suture, said to have 




George Fox's apparatus, 



FRACTURES OF THE CLAVICLE. 233 

been suggested and practised by Langenbeek, 1 I Lave only to say that I 
trust, for the reputation of surgery, and the good of the patients, the 
practice of this distinguished surgeon will find few imitators. 

Finally, while I deprecate incautious assumptions in regard to the 
capabilities of any form of dressing for broken collar-bones, a disposi- 
tion to which is manifested by more than one advocate of special plans, 
I am ready to declare my preference for an apparatus consisting essen- 
tially of a sling, axillary pad, and bandages to secure the arm to the 
chest. Among the considerable variety of dressings which I have used, 
this has seemed to me most simple in its construction, the most comfort- 
able to the patient, the least liable to derangement (if I except Velpeau's 
dextrine bandage, and certain other forms of "immovable" dressings), 
and as capable as any other of answering the several indications pro- 
posed, while the patient is permitted to walk about. 

Xo apparatus is better able to answer the first indication, namely, to 
" carry the shoulder up," than the sling. Indeed, in nearly all the 
forms of dressing hitherto devised, the sling is employed for this pur- 
pose. The bandage carried beneath the elbow is, in effect, a sling. In 
a few instances, men of no practical experience have sought to substitute 
an upward pressure in the axilla for the sling ; but it is scarcely neces- 
sary to declare the absurdity of this practice, inasmuch as no patient 
will be found willing to submit to it beyond a few hours. 

It is proper to say, however, that some surgeons, whose opinions are 
entitled to respect, believe that it is quite as important to depress the 
sternal fragment as it is to elevate the acromial, the outer end of the 
sternal fragment being lifted, more or less, by the action of the sterno- 
cleido-mastoid muscle. No doubt this is one of the difficulties with which 
we have to contend in our efforts to restore the two fragments to the 
original line of the axis of the bone. 

But then the elevation of the sternal fragment is only slight in any 
case. The rhomboid ligament quickly arrests its displacement in this 
direction, so that the marked projection of the outer end of this fragment 
is due rather to the depression of the outer fragments than to an eleva- 
tion of the inner. 

Inclination of the head to the side of the fractured limb will allow the 
sternal fragment to fall ; but it is impossible for the patient to maintain 
this position for any length of time. A compress laid over the sternal 
fragment, and held in place by adhesive straps or bandages, will lie found 
totally inefficient. Dr. Moore has adopted a more ingenious and philo- 
sophical method, by calling into requisition the clavicular fibres of the 
pectoralis major to antagonize the sterno-cleido-mastoid. Indeed, this is 
one of the essential principles upon which he rests the superior claims of 
his dressing; and I have myself observed that when, in the case of a 
recent fracture, the elbow is thrust behind the body, the outer end of the 
sternal fragment is depressed. Nevertheless, I have certain theoretical 
and practical objections to the doc-trine as taught so ingeniously by Dr. 
Moore. My theoretical objection is that the clavicular fibres of" the pec- 
toralis major will soon, under the continual strain, become relaxed, and 

1 Langenbeek, Dawson, Med. Rec., May 20, 1882. 



28 l FRAOTU i: ES OF Til E CLAVICLE. 

after a little time cease to accomplish what they did at first. This is a 
law in regard to the action of muscles put upon the strain, as every sur- 
geon knows. It may be supposed that, if the pectoral muscle is thus ren- 
dered h-ss competent to depress the fragment, the sterno-cleido-mastoid 
will be rendered, also, less competent to elevate the fragment; but this 
is DOl Btrictly true: the latter operates at right angles with the axis of 
the hone, and to great advantage, whilst the former acts very obliquely, 
and to a corresponding disadvantage. 

The practical objection which I have to offer is, that the dressings 
required to maintain this position are exceedingly liable to cause excori- 
ations and to become disarranged, and that in fact this has happened in 
all, or nearly all, of the cases which have been observed by me. More- 
over, whatever cause may be assigned for the failure, the results have 
been no better, so far as overlapping and deformity are concerned, than 
when my own dressings have been used. 

The second indication, namely, "to carry the shoulder back," is cer- 
tainly more difficult of accomplishment than the first, and it is only im- 
perfectly met by my own method, or by any other form of sling dressing. 
Desault taught that when the arm was lifted by the sling, or by any 
mode of pressure beneath the elbow perpendicularly, the shoulder was 
necessarily carried back. This is probably true, but its effect is not 
very marked. The ordinary figure of 8, which might at first be sup- 
posed to be the most rational mode of effecting this purpose, has long 
since been proved to be a failure. None of the contrivances to hold the 
shoulders back by bands which traverse the axilla, made fast to back- 
splints, have done any better. They all cause excoriations, and soon 
become intolerable. Dr. Sayre's adhesive plaster band, attached to the 
upper part of the humerus, below the axillary margin, either loosens or 
excoriates, also, and in the end proves inefficient. 

After all it must be said, that the indication "to carry the shoulder 
hack."' except so far as it incidentally accomplishes the indication "to 
carry the shoulders out," and thus obviate the overlapping of the frag- 
ments, is relatively unimportant. It is seldom that the falling forwards 
of the shoulders is very marked, or in itself a source of deformity; but 
carrying the shoulder back does diminish or overcome the riding of the 
fragments, and in this view alone is it important, and for this reason, 
Burgery will he indebted to any one who devises a method by which this 
position of the shoulder can be maintained until the union of the frag- 
ment- i< consummated. 

The third indication is "to carry the shoulder out," by which means 
it is proposed to overcome, directly, the riding of the fragments. We 
have Been that this may be accomplished, indirectly, by carrying the 
shoulder hack ; but, unfortunately, no means has yet been found by 
which this f;ii! be done and permanently maintained, while the patient is 
in the erect or sitting posture. 

The thick axillary pad, and all other devices by which it is proposed 
to act upon the humerus as a lever, and thus force the shoulder out, 
have totally failed or proved eminently mischievous. In short, I may 
say that this indication can, in my opinion, be effectually accomplished 
in only one way. and that i<. by laving the patient upon his back on a 



FRACTURES OF THE CLAVICLE. 



235 



Fig. 59. 



flat, firm mattress, and thus pressing the base and inferior angle of the 
scapula strongly and steadily against the back. The requisite pressure 
upon the scapula cannot be maintained by any plan yet contrived while 
the patient is in the sitting or standing posture, and especially when 
permitted to walk about. We shall be warranted therefore in attempting 
to accomplish this indication fully in only rare and exceptional cases. 
If a slight overlapping and deformity were to cause any appreciable 
diminution of the strength or usefulness of the arm, patients might pro- 
perly enough be subjected to such restraints for a few weeks ; but expe- 
rience has shown that such displacements do not, in any degree, maim 
the arm. Whether in the case of women, in examples of unusual dis- 
placement, the danger of disfigurement would warrant a resort to this 
method, must be left to the judgment of the surgeon and the choice of 
the patient; but in adopting what may be termed the "posture" treat- 
ment, it will be advisable also to em- 
ploy the sling, pad, and bandages in 
the manner hereafter to be described. 

The mode of dressing a fractured 
clavicle which, while the patient is at 
liberty to walk about, will secure the 
best results with the least suffering and 
annoyance, is as follows : 

The arm hanging perpendicularly 
beside the body, a sling is placed under 
the elbow and forearm, and tied over 
the opposite shoulder. An axillary 
pad. composed of cotton batting in- 
closed in a cloth cover, is placed well 
up in the axilla, and the elbow is then 
secured firmly to the side of the body 
with several turns of a roller. 

Dr. Coates. in the excellent paper 
already referred to. calls attention to 
the danger of making too much pres- 
sure upon the brachial artery and nerves, 
when the axillary pad is used, and the 
arm is, at the same time, carried for- 
wards upon the body. In bringing the 
elbow forwards, bo as to lay the forearm across tin- body, the humerus is 
made to rotate inwards, and the brachial artery and nerve- arc brought 
into more direct apposition with the pad: 1 while in the position which I 
have recommended and practised hitherto, these nerves and vessels are 
removed in a great measure, 1'Ut not entirely, from pressure. 

The pad should be no thicker than is oecessary to fill completely the 
axillary space, its purpose being to steady the arm. and. in some slight 
degree, to counteract the action of those muscles which tend t«. displace 
the shoulder inwards. It should be long enough jj, it< anteroposterior 
diameter to project distinctly in front and behind, otherwise it will not 




The author's dressing for fractured 
clavicle. 



I -.iii. ]». 62. 



PB ACT! R ES OF THE CLAVICLE. 

keep its place. In the adult it needs to be six or seven inches long. In 
the direction of the axis of the limb, its length should be less, perhaps 
lour inches. Being now well pressed up into the axilla, and secured 
with a needle and tnread to the upper edge of the roller which encircles 
the lower pari of the arm and the body, it will keep its position and 
serve some useful purpose. 

The Bling may be made of cotton or flannel cloth, and suspended from 
the opposite shoulder by the aid of four tapes, a broad and thick pad of 
folded cloth being laid upon the shoulder to support the knots. A con- 
siderable experience lias satisfied me that the stuffed collar, used in the 
Fox dressing, possesses no advantage as a means of suspension. The 
leather sling, also, in use in some hospitals, is liable to the objection that 
it cannot be stitched to the roller, which encircles the body and lower 
part of the arm, in the manner I shall hereafter describe. 

The roller should be made to encircle the lower fourth of the arm, 
and a few turns should pass beneath the forearm as far forwards as the 
hand, in this manner securely fixing the elbow and forearm against the 
side and front of the body. 

If thought necessary, the hand may be supported by a loop of band- 
age passed under the wrist and tied over the neck. 

Finally, in order that this dressing may retain its place and serve its 
purpose most effectually, its several parts should be stitched together 
thoroughly wherever the dressings cross or approach each other. In no 
other way can anything like permanency be insured in a portion of the 
body so movable as the shoulder and chest; but even with this precau- 
tion, daily attention and occasional readjustment are generally required. 

Treatment of Incomplete Fractures of the Clavicle. — In case of par- 
tial fracture of the clavicle, accompanied with a persistent bend in the 
line of* the axis of the bone, it is proper to attempt the replacement of 
thr fragments by direct pressure. The ends of the bone being fixed, we 
cannot, as in the case of a partial fracture of other long bones, employ 
leverage; and with direct pressure alone, applied in a degree which 
mighl 1m- regarded as incurring no danger of causing a complete frac- 
ture or of a dislocation, our chances of success are very small. I can- 
not Bay that I have ever succeeded in accomplishing anything in this 
way, although I have often made the attempt, and would always advise 
others to do the same. A failure, however, to restore completely the 
lino of the axis of the bone is not. I imagine, a matter of great conse- 
quence, since, a- has already been fully explained when speaking of 
partial fractures in general, the natural form will be in most, if not in 
all cases, completely restored after the lapse of a few months or years. 
This observation applies especially to partial fractures occurring in child- 
hood aid infancy. I have no experience as to what is the result of a 
Bimilar deformity loft after a partial fracture in the adult. 

Aj to the method of dressing these fractures, it need not differ from 
thai recommended for complete fractures: hut in a majority of these 
cases I 1 1 ;i \ « ■ thought it sufficient to place the arm in a sling, with a 
bandage around the elbow and body to keep the arm at rest; or I have 
directed the mother to make the sleeve fasl to the front of the dress with 
tapes; <>r the hand and arm of the child may he withdrawn from the 



FRACTURES OF THE BODY OF THE SCAPULA. 237 

sleeve and placed across the body inside the dress, and secured in this 
position by a belt around the waist. In this case, of course, the dress 
must remain upon the child until the cure is completed. The axillary 
pad can seldom, if ever, serve any useful purpose. 

Union occurs with great rapidity, sometimes as early as the seventh 
or tenth day : but the arm ought to be kept quiet, as a matter of safety, 
two or three weeks. 

For a more full consideration of the subject of partial fractures of 
the clavicle, the reader is referred to the chapter on Lk Incomplete 
Fractures." 



CHAPTER XX. 

FKACTTJKES OF THE SCAPULA. 

Fractures of the scapula may be divided into those which occur 
through the body, the neck, the acromion process, and the coracoid. 

§ 1. Fractures of the Body of the Scapula. 

Under this title I propose to consider not only fractures of the 
"body," properly speaking, but also fractures of the angles and of the 
spine. 

Causes. — The scapula is usually broken by the fall of some heavy 
body directly upon the bone, or by some severe crushing accident, by 
the kick of a horse, by a fell upon the back ; in short, by direct causes 
alone, and by such causes as operate with great violence. 

Malgaigne says that a Doctor Heylen published an example of this 
fracture, which he believes to have been* the result of muscular action, 
occurring in a man forty-nine years old. The case, however, is not 
stated so clearly as to relieve us entirely of a doubt as to the nature and 
cause of the accident. 

I have myself recorded six cases which have been under my treat- 
ment : and I have seen ;i few other examples of fractures of the body of 
the scapula not caused by firearms. There are two cabinel specimens of 
fracture of the body of the scapula below the spine in the Pennsylvania 
Medical College, and two involving the spine. Dr. Mutter had in bis 
collection n fracture of the posterior angle, and Dr. March had ;i speci- 
men of fracture of the body. I believe, also, thai in the collection of 
the late Dr. Charles Gibson, of Richmond, there were one mi- two speci- 
mens of tlii- fracture. I know of no other museum specimens in this 
country except my own of partial fracture, described in the chapter on 
"Partial Fracty 

Ravaton, after a practice of fifty years, declared that lie had q< 
seen a fracture of the scapula except as it had been produced by fire- 
arms. Among 2358 fractures reported from Hotel Dieu during ;i period 
of twelve years, only four examples of* fracture of tie- scapula are 



238 



FRACTURES OF THE SCAPULA. 



recorded; and, at Middlesex Hospital, Lonsdale has noticed, among 
L901 fractures, only eight of the body of the scapula. 

The infrequency of this fracture is no doubt due in a great measure to 
the elasticity of the ribs, to the mobility of the scapula, and to the soft- 
ness of the muscular cushion upon which it reposes. 

Symptoms. — Since this bone is seldom broken except by great force 
directly applied, the usual signs of fracture are likely to be concealed 
by the speedy occurrence of swelling. It is for this reason that it be- 
comea necessary, generally, that the examination should be made with 
great care before we can safely determine upon the diagnosis. I have 
more than once had occasion to correct the diagnosis of other practi- 
tioners, who believed they had discovered a fracture of the scapula. 

When, however, the line of the fracture has traversed the spine, and 
any considerable displacement has occurred, one may recognize the 

fracture easily by merely carry- 
Fig. 60. i n g the finger along the crest. 

If the fracture has occurred 
through the body, below or above 
the spine, or through either of 
the angles, the displacement may 
not be so easily recognized. The 
surgeon ought then to trace care- 
fully with his finger the outlines 
of the scapula ; and this he will 
be able to do more satisfactorily 
if he places the scapula in such 
positions as elevate its margins 
and render them more prominent. 
In examining the posterior angle, 
the hand of ihe injured limb may 
be placed upon the opposite shoul- 
der, the forearm being carried 
across the front of the chest ; but 
in searching for a fracture below 
the spine, the forearm ought to 
be laid across the back. 

Crepitus, which is not always 
present owing to the fact that the 
fragments overlap completely, or 
because they have been widely 
separated by the action of the 
muscles, may generally be de- 
tected by placing the palm of the hand upon some portion of the scapula, 
so as to -ready the fragment upon which it rests, while the arm is moved 
backwards and forward-, and in various other directions, until their broken 
surfaces are brought into contact. 

Some degree of embarrassment in the motions of the shoulder and 

arm must always result from this fracture: sometimes this embarrassment 

L r r<;it. hut it ought not to be considered ever as diagnostic of a 

fracture, since it maybe produced equally by a severe contusion; and 




nire of the posterior nngle of scapula, 
with fissure. Mutter's collection, specimen C, 
No. 1-7. 



FRACTUEES OF THE BODY OF THE SCAPULA. '239 

even when it is accompanied with a fracture, it is due rather to the con- 
tusion than to the fracture. 

Pathology. Seat, Direetian, etc. — Of incomplete fractures of the sca- 
pula, I have already mentioned that I have seen one example. 

Malgaigne thinks that he has seen one vase of incomplete fracture, 
which occurred in a man who was injured by the fall of a heavy block 
of stone upon his back; but as the patient recovered, his diagnosis must 
remain doubtful. I know of no other recorded examples. 

Complete fractures occur most often below the spine, and they are 
generally oblique or transverse, sometimes nearly longitudinal. 

Fractures involving the spine are noticed occasionally: but I am not 
aware that any one has ever seen a specimen of a fracture of the spine 
alone, although many surgeons have spoken of them. 

I have mentioned one example of a fracture of the posterior angle as 
being in the cabinet of Dr. Mutter, of Philadelphia. Malgaigne seems 
to doubt its existence, but speaks of it as a fracture which surgeons 
have *■ imagined." 

Occasionally the bone is broken into more than two fragments. 

As a result of the fracture there is usually more or less displacement; 
generally, if the fracture is below the spine and transverse, and especially 
if its direction is oblique from before backwards and downwards, the 
inferior fragment is displaced forwards, or forwards and upwards, by the 
action of the serratue major anticus, or of the teres major, whilst the 
superior fragment is inclined to fall backwards, and sometimes it is carried 
upwards and backwards, following the action of the rhomboideus major. 

In cases of comminuted fractures, and occasionally in simple fractures, 
the direction of the displacement is reversed, or altogether changed, so 
that the lower fragment, instead of being in front, is behind the upper 
fragment; and instead of overlapping the two fragments are more or 
less drawn asunder. These are deviations which are not easily ex- 
plained, but which depend, perhaps, rather upon the direction of the 
blow than upon the action of the muscles. 

In a few cases there is no displacement in any direction, although 
the crepitus and mobility sufficiently demonstrate the existence of a 
fracture. 

Prognosis. — If displacement actually has taken place, it will be found 
very difficult, as we shall see when we come to consider the treatment, 
to hold the fragments in apposition until a cure is completed; so that 
they are pretty certain to unite with a degree of overlapping, or other 
irregularity. 

Lonsdale. Lizare, Chelius, Nelaton, Gibson, Malgaigne, and others 
have spoken of the difficulty or impossibility generally of keeping these 
fragments in place. Nelaton and Malgaigne, indeed, confess thai they 
have never succeeded; Gibson declares that it is scarcely possible; 
whilst Chelius affirms that if the fracture is Dear the angle, the cure is 
always effected with some deformity. 

But then it is not probable that 'the patient will ever suffer any Berious 
inconvenience from this irregular union of the fragments, since the 
perfection of its function depends less upon any given form or size than 
in the case of almost any other large bone; and if. as has been observed 



Jhi FRACTURES OF THE SCAPULA. 

by Lonsdale, the free use of the arm is not recovered for some time, or 
it*. a< has been noticed by B. Bell, a permanent stiffness results, these 
should be regarded as due to the injury which those muscles have 
Buffered which envelop the scapula, or to some injury of the ligaments 
and muscles which Burround the shoulder-joint. 

In some few examples upon record, the bone has been so comminuted, 
and the soft pans adjacent so much injured, that suppuration and necro- 
sis have ensued. And in one case of gunshot fracture of the scapula, 
resulting in necrosis, I have had occasion to remove the entire scapula. 1 

The case referred to is briefly as follows: Private "\Vm. Murphy, 73d 
Regt. N. V. Vol.. 83t. 33, was admitted to my service, Bellevue Hos- 
pital. February, 1866. He stated that he was wounded at Fredericks- 
burg, December 13, 1862, by grape-shot, which fractured both the scap- 
ula and head of the humerus. Six days later the head and a portion of 
the shaft of the humerus were removed. At a later period necrosis 
attacked the scapula, and I removed the entire scapula, including the 
acromion and coracoid processes, at Bellevue, February 10, 1866, in the 
public- amphitheatre. Subsequently the patient and the removed scap- 
ula were brought before the New York Pathological Society. At this 
time lie bad recovered very good use of the limb, and was able to con- 
tract effectively the biceps and coraco-brachialis, although their upper 
points of attachment were only cicatricial tissue. Murphy received a 
pension, and is subsequently reported by the pension officers as having a 
large cicatrix over the site of the scapula, the wound made by the resec- 
tion having healed completely within a few months after the operation. 
They report, also, some points of bone, which must have been reproduc- 
tion-. The arm was atrophied, and of little value. He died June 24, 
1874, having survived the operation more than eight years. Dr. Otis, 
compiler of the Surgical History of the War of the Rebellion, who has 
gathered a complete account of this case, remarks that ww it affords per- 
haps a solitary example of a successful extirpation, for the results of shot 
injury, of the scapula, with preservation of the upper extremity." 

Treatment. — In the treatment of this fracture, the first object with all 
surgeons has been to restore the fragments to place, and this they have 
chiefly sought to accomplish by position ; after which they have en- 
deavored to immoblize the fragments by bandages, etc. 

In seeking to accomplish the first indication, they have placed the 
Bhoulder and arm in a greal variety of postures. Nearly all seem to 
have regarded it as of some importance that the shoulder should be 
elevated, bo as to relax the muscles attached to the upper and back part 
of the Bcapula, and thus permit the upper fragment to fall downwards 
ami forwards. 

If we confine our remarks first to fractures through the body, and do 
not include fractures of the inferior angle, this indication is the only 
one which Nekton and Mayor have sought to accomplish, and for this 
purpose they employ a simple sling; while Amesbury, Liston, Lons- 

1 Surgical History of the War of the Rebellion, vol. ii., "Washington, 1876, pp. 
. 't. 198, 199, 500. Proceedings of X. V. Patholog. Soc, 1866, in Med. and 
r, vol. xiv. j. 872. 



FRACTURES OF THE BODY OF THE SCAPULA. 241 

dale. S. Cooper, South. Skey. Miller. Pirrie, have added to the sling a 
bandage or roller, which is made to inclose snugly the body and arm. 

Erichsen uses the body bandage alone, as in fractures of the ribs, 
while B. Cooper. Lizars. and Ta vernier employ a bandage which in- 
closes not only the body, but also the arm: neither erf these last-men- 
tioned surgeons recommends a sling, or any other means to elevate the 
arm. 

Johannes de Gorter advises that a sling shall be used, but that the 
elbow shall be lifted away from the side of the body, so as to relax the 
deltoid. Chelius and Desault recommend the same position, but with 
the addition of an axillary pad. whose apex shall be directed upwards, 
secured in place with appropriate bandages. 

Pierre d'Argelata used also an axillary pad. but instead of a wedge he 
recommended a simple roll; and instead of lifting the elbow away from 
the body, he directed that the elbow should be secured against the Bide, 
making use of the axillary roll as a fulcrum. 

Petit and Heister advised that the elbow and forearm should be car- 
ried forwards upon the front of the chest, and secured in this position. 

In the treatment of no other fracture perhaps have surgeons differed 
more widely as to the indications than in this, since, as we have seen, 
recommend the elbow to be carried from the body, and some that 
it shall be niade to approach the body: one directs that the elbow shall 
fall perpendicularly beside the chest, a second prefers that it shall be 
carried a little back, and a third that it shall be brought well forwards. 
In <>ne thing al<»ne have they nearly all agreed, namely, that the elbow 
shall be lifted; and generally also it lias been recommended that the 
arm. forearm, and body shall be confined by sufficient bandages to insure 
quietude. It might be proper t<» conclude, therefore, that the -ling and 
bandage constitute all of the apparatus which is necessary or useful : 
and that it is relatively unimportant whether the elbow i- near or remote 
from the body, or whether it is in front of. or behind, or beside the chest. 

Such, indeed, i- the conclusion to which I have myself arrived: yet 

if. in relation to the position of the elbow, a choice were to be expressed, 

I would give the pr that in which the arm is laid vertically 

the body, or. perhaps, with the elbow a little inclined backwards, 

ipletely as possible the teres major. 

It is quite probabL . that no -ingle position will be found of 

universal application : and perhaps it would be more safe to advise the 

_ on in any _ - first to reduce the fragments :i- completely as 

de by manipulation, and then t<» place the arm in such a position 

a-, upon careful experiment in this particular instance, he shall find 

enables him best to retain them in p] 

If. however, the fracture i- such a- to have separated the inferior 
angle from the body, it will be well to follow the advice of Beyer and 

there, and to place a compress in front of* the inferior angl< , 
the greater tendency to displacement in this direction. This compress 
will more effectually accomplish this indication if the roller with winch 
it \b t to the body, and with which we seek to immobilize 

scapula and chest, is turned from before backwards, or in a direction of 
antagonism to the action of the muscles which produce the displacement. 

16 



242 



FRACTURES OF THE SCAPULA. 



Desault, with Chelius and Bransby Cooper, lias recommended also, in 
the case of a fracture through the angle, thai (lie forearm .should be 
acutely flexed upon the arm. and thai the hand should be placed in front 
of the chest, upon the sound shoulder, a position which is always irk- 
Bome, and sometimes insupportable, and which does not offer in any case 
Bufficienl advantages to render it worthy of a trial. 

^ 2. Fractures of the Neck of the Scapula. 

If by tin 1 • > neck" of the scapula surgeons mean that slightly con- 
Btricted portion of this bone which is situated at the base of the glenoid 
cavity — and it is to tliis portion, we believe, that anatomists have gener- 
ally applied the term "neck" (we will take the liberty of calling this 
the " anatomical " neck) — then its fracture is certainly very rare. In- 
deed, the existence of this fracture, uncomplicated with a comminuted 
fracture of the glenoid cavity, is denied by Sir Astley Cooper, South, 
Erichsen, and others. Mr. South says there is no such specimen in any 
of the museums in London ; and I have not been able to find one in any 
of the American cabinets. Dr. Valentine Mott has said to me that he 
had never seen a specimen, and that in the natural condition of the bone 
he regards its occurrence as impossible. Such, I confess, also, is my 
own conviction. 

It*, however, it is intended, in speaking of fractures of the neck of the 
scapula, to refer, as Sir Astley Cooper has done, only to fractures ex- 
tending through the semilunar notch, behind the root of the coracoid 
process (" surgical " neck), then its existence is certain ; yet the fracture 



Fig. 61. 



Fig. 62. 





Comminuted Fracture of the 
glenoid cavity. 



Fracture of the neck of the scapula; 
according to Sir Astley Cooper. 



is not common. Duverney has reported one example, the existence of 
which he established by a dissection. The coracoid process was broken 
nt the Bame time, bul the fracture through the surgical neck was distinct 
from this; and Sir Astley has recorded three examples in which the diag- 
was very clearly made out, yet not actually proved by an autopsy. 



FRACTURES OF THE ACROMION PROCESS. 243 

In Holmes's Surgery it is stared that there is one specimen in the 
museum of Guy's Hospital : another, in which repair lias taken place, 
in the museum of the Royal College of Surgeons; and the writer refer.-, 
also, to the ease reported by Duverney in 1751. 1 

Perhaps some of the eases, diagnosticated during the life of the patient 
a- fractures of the neck of the scapula, were fractures of the lower or an- 
terior lip of the glenoid cavity : but I have never found such a specimen 
in any collection of hones which I have yet examined, and it must be 
admitted to be exceedingly rare. 

Sj/mjrtoms. — Sir Astley Cooper justly remarks that kW the degree of 
deformity produced by a fracture of the surgical neck of the scapula 
depends upon the extent of laceration of a ligament which passes from 
the under part of the spine of the scapula to the glenoid cavity. If this 
he torn" (and to this we ought to add the ligaments passing from the 
coracoid process to the clavicle and acromion process — coraco-clavicular 
and coraco-acromial). " the glenoid cavity and the head of the os humeri 
fall deeply into the axilla, but the displacement is much less if this re- 
mains whole." 

The usual signs are. a depression under the acromion process, the 
same as in dislocation of the head of the humerus downwards, but not 
bo deep; the head of the humerus felt, perhaps, in the axilla; crepitus, 
ami the immediate recurrence of the displacement whenever, after the 
reduction has been fairly accomplished, the arm is left unsupported. 
The crepitus is best discovered by resting one hand upon the top of the 
shoulder in such a manner as that a finger shall touch the point of the 
process, while the arm is rotated and moved up and down by the oppo- 
site hand. It may also be easily ascertained that the coracoid process 
moves with the humerus instead of the scapula. Occasionally the acci- 
dent is accompanied with paralysis of the arm, from pressure upon the 
axillary nerves ; and a rupture of the axillary artery is also mentioned 
by Dugas ■ 

Treatment. — The indications of treatment are three, namely, to carry 
the head of the humerus, with the glenoid cavity, etc., up, to carry it 
out, and to confine the body of the scapula. The first is accomplished 
by a sling, the second by a pad in the axilla, and the third by a broad 
roller carried repeatedly around the arm and chest and across the shoul- 
der. In short, the treatment is essentially the same as that which I 
have recommended for a broken clavicle 

§ 3. Fractures of the Acromion Process. 

Examples of fracture of the acromion process have been reported by 
Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, Nelaton, Mal- 
gaigne, West, 3 Brainard,' Stephen Smith, and others. I have myself 
Been five cases. 

In the case seen by Cooper it entered the articulation of the clavicle, 

1 Holmes's Surgery, vol. ii. p. 770. Amer. <<1 . 1870. 

1 Remarks on F >ula, by L. A. !> I A.mer. Journ. Med. 

Jan. L868 

West, Penin. Journ. of M v. p. 264. 

4 Brainard, B it. M d. ad S e Journ., vol. xxxi. p. 601. 



244 FBACTUBBS OF THE SCAPULA. 

and produced al the same moment a dislocation. Malgaigne says it 
occurs generally farther up, and posterior to the attachments of the 
clavicle, "near the junction of the diaphysis with the epiphysis," and 

that the fracture is in mosl cases transverse and vertical ; but Nekton 
siw a case in which the fracture was oblique. In the case reported by 
C. West, of Eagerstown, Md., the fracture was through the base of the 
process. In two of the examples seen by me the fracture was in front 
of the clavicle: in the third, occasioned by the fall of a barrel of flour 
upon the shoulder, the fracture occurred at the acromioclavicular articu- 
lation, and was accompanied with an upward dislocation of the outer end 
of the clavicle; in the fourth the fracture occurred at the same point, 
but there was neither displacement of the clavicle nor of the process, the 
fracture being only recognized by the crepitus and motion. The fifth, 
a man ;et. 31, was brought to my notice by Dr. Thomas J. Sabine, sur- 
geon to Bellevue Hospital, Oct 23, 1876. The patient had been struck 
by a policeman's club. There was distinct crepitus, the fracture being 
posterior to the acromio-clavicular junction, but there was no displace- 
ment of the fragments or of the clavicle. 

There is some reason to believe, I think, that a true fracture of the 
acromion process is much more rare than surgeons have supposed, and 
that in a considerable number of the cases reported there was merely a 
separation of the epiphysis; the bony union having never been com- 
pleted. If such fractures or separations occurred only in children, very 
little doubt might remain as to the general character of the accident; 
hut the specimens which I have found in the museums, and the cases 
reported in the books, have been mostly from adults. It is more diffi- 
cult, therefore, to suppose these to be examples of separation of epiphy- 
Bes, hut I am inclined to think that in a majority of instances such has 
been the fact. It is very probable, also, that in the case of many of the 
specimens found in the museums, called fractures, the histories of which 
me unknown, they were united originally by cartilage, and that in the 
process of boiling, or of maceration, the disjunction has been completed. 
The narrow crest of elevated bone which frequently surrounds the pro- 
bl the point of separation, and which Malgaigne may have mistaken 
for callus, i- found upon very many examples of undoubted epiphyseal 
separations which I have examined; and this circumstance, no doubt, 
has tended t<» strengthen the suspicion that these were cases of fracture. 

The opinion is confirmed by the remark of Mr. Fergusson that a frac- 
ture «.f this process is an accident 4, of rare occurrence." "I have dis- 
i. he adds, "a number of examples of apparent fracture of the end 
of this process; but in such instances it is doubtful if the movable portion 
had ever been fixed to the rest of the bone." Dr. Jackson, in a letter to 
me, says there are four specimens in the museum of the Massachusetts 
Medical College, and in the museum of the Boston Society for Medical 
Improvement, which might easily be mistaken for fractures, but which 
only illustrate to how late a period the bony union is sometimes delayed. 
In one specimen the patient could not have been less than forty years of 
age; "the acromial process of each scapula was fully formed, but having 
no bony union whatever with the hone itself. The union was ligamen- 
tous, hut strong and close." 



FRACTURES OF THE ACROMION PROCESS. 



245 



To the same class belong several specimens in my own collection; 
specimens 16-3 and 907 in Dr. March's collection in Albany: TOT in the 
Albany College collection: two specimens in the Mutter, and one in the 
Jefferson Medical College museums. 

I wish to mention also, that in the case of my own specimens of epi- 
physeal separation, as well as most of the specimens which I have 
examined, the ends of the fragments were closed with a compact bony 
tissue. 

The mode of development of the scapula will explain these cases. The 
scapula is formed from seven centres ; namely, one for the body, one for 
its posterior border, one for its inferior border, tw T o for the acromion 
process, and two for the coracoid. Ossification of the body exists to a 
certain extent at or near the period of birth. It commences in one of 

Fig. 63. 




Scapula, with epiphyses. (From Gray.) 



the centre- of the coracoid process, about one year after birth, and unite- 
to the body at about the fifteenth year. AH the other centres remain 
cartilaginous until from the fifteenth to the seventeenth year, when 
ossifieatioii commences, and is completed by a common union among all 
part-, usually between the twenty-second and twenty-fifth years. 

No doubt, however, a fracture of thia process does occasionally take 
place. In addition to my own. I have already mentioned several ether 



A. IT l; ES OF Til K SCA PULA. 

examples, some of which have been confirmed by dissection, and in the 
case mentioned by Stephen Smith, an autopsy, made three weeks after 
the accident, showed a fracture in front of the clavicle without displace- 
ment, the periosteum covering it- upper surface not being torn: the 
fragment could he turned back as upon a hinge. 

Prognosis "'Inn tin- Fracture is in front of the Clavicle. — The process 
ally unites with a Blight downward displacement. This occurred in 
the two examples seen by me: but in such cases the motions of the arm 
are not in consequence much, if at all. impaired: unless, indeed, it is so 
much depressed as to interfere with the upward movements of the arm : 
a result which 1 leister erroneously supposed was inevitable. 

Sir Astley Cooper says that a true bony union is rare in these frac- 
tures, and that there generally results a false joint, the fragments uniting 
by a fibrous tissue; hut sometimes the surfaces, instead of uniting either 
by bone or ligament, become polished and even eburnated. 

Malgaigne has noticed, also, in a specimen contained in the Dupuy- 
tren museum, a hypertrophy of the loAver fragment, this portion having 
a diameter nearly twice as great as that of the portion from which it was 
detached. 

Prognosis when the Fracture is through the Articulation of the 
( 'lavicle. — Where neither the fragments nor the clavicle are displaced, 
the prognosis ought to be favorable : but in case the clavicle is dislocated, 
there will he encountered the same difficulties as in the case of simple 
acromial dislocation of the clavicle, or even more serious difficulty, and I 
do not see how it can be expected that a perfect reduction should be 
maintained. 

Prognosis whi n th Fracture is Posterior to the Articulation of the 
< 'lavicle. — In these cases, if there is little or no displacement, the prog- 
nosis is favorahle; but if the fragments are displaced, a perfect adjust- 
ment may he difficult. 

Symptoms. — Where no displacement exists, the diagnosis must always 
he difficult, if not impossible. In such a case we could only be instructed 
by the manner in which the injury had been received, by the contusion, 
and by the presence of mobility or crepitus. 

In examples attended with displacement, if no swelling is present, the 
finger, carried along the spine of the scapula to its extremity, will easily 
detect the fracture by the abrupt termination or elevation of the process, 
or by the presence of a fissure, or a depression: but as to the other 
symptoms, they must depend very much upon the point at which the 
fracture bas taken place. If in front of the acromio-clavicular articula- 
tion, the position of the arm in its relations to the body will not be 
changed ; but if the fracture is through the articulation, and a disloca- 
tion of the clavicle results, or if it is behind the acromio-clavicular 
articulation, the arm. having in either ease lost the support of the clavi- 
cle, will he inclined to assume the same position that it does in a 
fracture of the clavicle: that is. the Bhoulder will be disposed to foil 
downward-, inwards, and forward-. 

Treatment. — If the fracture has taken place in front of the acromio- 
clavicular articulation, no doubt the most rational plan of treatment, if 
kirns at the accomplishment of a perfect bony union, is that recom- 
i •■ Ipech : that is, placing the patient in bed. upon his back, 



FRACTURES OF THE CORACOID PROCESS. 247 

and carrying the arm out from the body nearly to a right angle : since 
by this method the fragment is not only lifted, but the deltoid muscle is 
relaxed, and. consequently, the fragment is no longer forcibly drawn 
away from the spine of the scapula. If, therefore, the patient will sub- 
mit to this treatment for a sufficient length of time, the union must be 
accomplished with the least possible amount of displacement. But in 
the case of a fracture of the acromion process at the point indicated, 
only a few fibres of the deltoid muscle are attached to the fragment 
which has been broken off, and consequently, even in case no union took 
place, the muscular power of the arm could not be appreciably impaired. 
Nor would a slight tailing or depression of the fragment cause any em- 
barrassment to the motions of the shoulder-joint. 

For these reasons it is scarcely worth while to do anything more, in 
a great majority of cases, than to place in the axilla a pretty heavy 
wedge-shaped pad. with its apex upwards, and then secure the arm to 
the side with a sling and roller, the same as in the case of a fracture of 
the clavicle. 

If. however, the fracture has taken place at or behind the junction of 
the clavicle with the process, the indications of treatment will be, in all 
respects, the same as in the case of a fracture of the clavicle. 

§ 4. Fractures of the Coracoid Process. 

••The coracoid process.'* says Mr. Lizars, "is said to be broken off, 
but this I question very much ; it must be along with the glenoid cavity, 
or there must be a fracture of the neck of the scapula." 

Dr. Neill, of Philadelphia, has in his cabinet a specimen of separation 
of this process at about one inch from its extremity. The line of sepa- 
ration is somewhat irregular ; there is no callus, but it is united to the 
upper portion by a dried tissue, half an inch in length, and continuous 
with the periosteum. This has been regarded as an example of fracture; 
but although the scapula is large, and evidently belongs to an adult, the 
fact that the acromion process i- not yet united by bone renders it 
probable that this, also, is an epiphyseal separation. Prof. Charles 
- ai, of Richmond, Va., lias informed me also thai lie lias in his 
cabinet a dried specimen, from an adult, which has beeen broken ob- 
liquely near the end. but which is now united by a ligamentous <»r 
fibre - :' one line and a half in length. The fragment i- dis- 

placed a little forwards a- well as downwards. Reuben I>. Mussey, of 
Cincinnati, poss ry remarkable and conclusive example of this 

fracture. The humerus i- dislocated forwards, the head and neck being 
firmlv united to the neck and venter of the scapula, while at the same 
time the coracoid process is broken and displaced. Dr. -lack-on. of 
Boston, says tha d X". 453 in tie- museum of the Massachusetts 

Medical College seems clearly to have hen a fracture involving the base 
of tie process, and which, having taken place somewhere within 

a year of the death of the person, had become united by hone, and that 

just before death the process bad broken off. and so completely, as to in- 
volve a portion of the glenoid cavity.' 

1 The autl :< Deformities, op. cit. 



248 



FK A CTUKES OF THE SCAPULA. 



Fig. 64. 



Bransbj Cooper relates a case of fracture through the base, which 
after eight weeks, when the patienl died, was found to be united by a 
ligament. The acromion process was broken at the same time, and had 
united in the same manner. The head of the humerus was also broken 
and partly united. 1 One example is said to have occurred in the prac- 
tice of Dr. Arnott, at the Middlesex Hospital, London, in consequence 
of which the patient died, when a dissection disclosed the true nature of 
the accident. 3 Mr. South has also reported a case resembling somewhat 
Mussey's, but much more complicated. The humerus was partially dis- 
located forwards, the clavicle, acromion process, and the olecranon were 
broken as well as the coracoid process. Neither the fracture of the 
clavicle nor of the coracoid process was made out until after the patient 

died, which was on the fourth day; 
the fact of the existence of these 
fractures being then ascertained by 
dissection. 3 Holmes has reported a 
case. 4 Erichsen says there is in the 
museum of the University College a 
preparation showing a fracture at the 
base of this process, the line of frac- 
ture extending across the glenoid 
cavity. 5 Duverney, Boyer, and Mal- 
gaigne have also reported four addi- 
tional examples, confirmed by dis- 
sections. 6 

The existence of this form of frac- 
ture, established by at least nine or 
ten dissections, can no longer be de- 
nied ; yet it is often accompanied 
with serious complications, and such as have sometimes proved fatal. In 
the only two cases, however, in which I have had reason to believe that 
I had to deal with a fracture of this kind, the symptoms and termination 
were less grave, although they were both complicated with an upward dis- 
location of the outer end of the clavicle. A gentleman residing in the 
country was struck by a board which fell edgewise upon his shoulder. 
The fracture of the coracoid process does not seem to have been recog- 
nized by his Burgeon. An apparatus was applied to retain the clavicle 
in it- place, hut after three months, when he called upon me, it still 
remained displaced a- at first. During all of this time the apparatus 
had been steadily kept on. On laving off the dressing, I discovered that 
the coracoid process was detached, obeying constantly the movements of 
the head of the humerus, but being not at all subject to the movements 
of the scapula. Some months later I examined the arm again, and 
found the parts in the same condition as before, but the functions of the 
armjwere not impaired. A girl was admitted to Bellevue Hospital in 




Fnicture of the coracoid process. 



B. Co per, edition of Sir A-tlfv on Frac. and Disloc, Amer. ed., p. 380. 
• -.. p. 231. 
,-Chir. Tlev., 1840, vol. xxxii.. new series, p. 41. 
Sfed.-Chir. Trans., vol. \li. p. 1 17. 
5 Eri> - ; . p. 207. ''• Malgaigne, op. cit. . p. 



>12. 



FRACTURES OF THE CORACOID PROCESS. 249 

November, 1868, having fallen upon her left shoulder, and having sus- 
tained a complete luxation of the acromial end of the clavicle, upwards 
and outwards. Upon careful examination, a fracture of the coracoid 
process was also diagnosticated, indicated by both mobility and crepitus. 

By courtesy of Dr. James L. Little, of this city. I was permitted to* 
see. on the 4th of April. 1879. an example of this fracture in the person 
of John Gannon, aet. 38. Four days before he had been struck by an 
iron rod upon his shoulder, but at what precise point could not be deter- 
mined. There was no mark over the seat of fracture, and not much sign 
of contusion. The arm. forearm, and hand were completely paralyzed. 
The coracoid process seemed to be displaced inwards, or toward the 
median line of the body; but when the humerus was forcibly rotated 
outwards, the coracoid resumed its place, and if now pressure was made 
upon its extremity, it became again suddenly displaced, with a subdued, 
grating sensation. The presumption appears to be. that the fragment 
was reduced by external rotation of the humerus ; but this position could 
not be maintained on account of the severe pain which it caused. 

Dr. E. C. Huse. of Rockford. 111., has also recently reported a case — 
not confirmed, however, by an autopsy. 1 

E. Hulme believed that he had met with this fracture, caused by mus- 
cular action, in the person of a man who. in falling, was caught by his 
arm in such a way that it was drawn forcibly from the body. 2 

It has been generally stated that when this process is broken off, it 
will be carried downwards by the united action of the pectoralis minor, 
the short head of the biceps, and the coraco-brachialis muscles : but this 
will depend upon whether the coraeo-elavicular ligaments are ruptured 
also; a circumstance which is not very likely to occur, at least to any 
great extent : and in fact not one of the well-attested examples of tins 
fracture has ever been accompanied with any considerable displacement 
in this direction. 

Treatment. — In ;i case of simple fracture of the process, unattended 
with any other lesions, it has been recommended to place the arm in ;i 
sling, with the elbow advanced as much as possible upon the front of the 
chest, ;i> by this position we relax somewhat all of* the three muscles 
having attachment- to tin- process, and then to confine the scapula by ;i 
few turn- of a roller. It is not probable, however, that by these meas- 
ures we would accomplish enough to justify their continuance if they 
were found to be painful, or even exceedingly irksome. Patients under 
my observation have generally complained xi-ry much of tlie pain and 
discomfort attending this position of extreme flexion of the arm and fore- 
arm, first employed by Velpeau for fractures of the clavicle. Moreover, 
I do not think the fragments are generally displaced : and if they were, 
and the final union were to be accomplished solely by ligament, I think 
the usefulness of the arm would not be ;it ;ill impaired. Such, ;it least, 
has been my experience in tie- e recorded, and in both of 

which no bony union occurred. In Dr. Little's case rotation of the 
humerus outwards seemed to effect ;■ reduction, but upon what principle 

If , I . M ■ I 

If ilc • I, • ■••. vol ii. p J 



250 FRACTURES OP THE HUMERUS. 

precisely this position acted to effect the reduction T am not prepared to 
Bay; perhaps by drawing upon the coraco-brachialis and short head of 
the bicepi — uor am 1 prepared to say that it would accomplish the same 
result in any other case, yel it may deserve a trial. 

In the graver forms of the accident, where other bones about the 

b! Ider are broken or dislocated, or the limb lias suffered other severe 

injuries, which, as we have seen, constitute the larger proportion of the 
whole number, the treatment must generally have little or no regard to 
this particular injury. 



CHAPTER XXI. 

I KACTURES OF THE HUMERUS. 

It is nor sufficient to consider fractures of this bone as occurring 
through the shaft and its two extremities, as some systematic writers 
have done: since upon this simple arrangement it is impossible to base 
a natural division of their causes, symptoms, prognosis, and treatment. 

Wo shall find it necessary to consider — 

1. Fractures of the head and anatomical neck. (Intracapsular; 
non-impacted and impacted.) 

'2. Fractures through the tubercles. (Extracapsular; non-impacted 
and impacted.) 

3. Longitudinal fractures of the head and neck, or splitting off of the 
greater tubercle. 

4. Fractures of the surgical neck. (Including separations at the 
upper epiphysis.) 

o. Fractures through the body of the shaft. (Shaft below the surgi- 
cal nock and above the base of the condyles.) 

<'». Fractures at the base of the condyles. (Including separations at 
the lower epiphysis. ) 

7. Fractures at the base, complicated with fractures between the con- 
dyles, extending into the joint. 

x . Fractures or separations of the internal epicondyle. 

!». Fractures or separations of the external epicondyle. 

10. Fractures of the internal condyle. 

1 1. Fractures of the external condyle. 

of 208 fractures <»f the humerus examined and recorded by me, 51 
occurred through the upper third, 43 through the middle third, and 103 
through the lower third. An observation which is in contrast with the 
Btatemenl made by A.mesbury, and which has been repeated by Lizars, 
B. Cooper, Fergusson, Gibson, and others, that this bone is most often 
broken in its middle third, unless they intended to speak of fractures of 
the shafl alone. 

of the fractures belonging to the upper third, 6 were supposed to be 
epiphyseal separations, one was probably a fracture at or near the ana- 



FRACTURES OF THE HEAD AND ANATOMICAL NECK. 251 

tomical neck, with impaction and splitting of the tubercles, one was a 

fracture of the greater tubercle alone, and 44 were fractures at or near 
the surgical neck; some of them probably involving the shafl below the 
neck. 

Of the fractures belonging to the lower third. 22 were through the 
internal condyle, 29 through the external condyle, 18 were at the base 
of the condyles. 6 through the condyles and across the base at the same 
time. One at the epiphysis, the remaining 27 being through the shaft, 
but above the base. 

Unfortunately, surgical writers have not been agreed in the use and 
application of the terms '"head," "neck," "anatomical neck," and "sur- 
gical neck" of the humerus; and, as a consequence, their meaning is 
often obscure, and their teaching- are sometimes contradictory and 
absurd. 1 It is necessary, therefore, that we should define them more 
precisely. 

The "head" of the humerus is that smooth, elliptical surface, covered 
by cartilage and synovial membrane, which articulates with, and is re- 
ceived into, the glenoid cavity of the scapula. 

The ''anatomical" neck is the narrow line immediately encircling the 
head, and which receives the insertion of the capsular ligament. 

The "surgical" neck is that portion which commences at the lower 
margin of the tubercles, or at the point of junction between the epiphy- 
sis and the diaphysis. and which terminate- at the insertion of the pec- 
toralis major and latissimus dorsi, 

The ••neck" i< all of that portion included between the head and the 
insertions of the pectoralis major and latissimus dorsi; comprising not 
only the anatomical and surgical necks, but also the tubercles: which 
latter occupy the triangular space between these two. 

§ 1. Fractures of the Head and Anatomical Neck. (Intracapsular ; 
Non-impacted and Impacted.) 

Wractures of the Head. — The causes which have been found compe- 
tent to produce fractures of the bead are, the penetration of balls or of 

other missiles directly into the joint, producing thus a compound, and 
generally comminuted, fracture of the bead: and falls, or direct blows 
upon the shoulder, without penetration. 

When the fracture results from the direct penetration of some foreign 

body into the joint, it i- not only a compound fracture, but the bead of 

the bom- is almost necessarily broken into many fragments. If the 
patient recovers, sooner or later the fragments have generally to be 
removed, or resection has to be practised. 

Examples of fractures of the bead of the humerus, not caused by 
penetrating injuries, ami not accompanied with fracture of the anatomical 
neck, or of the tubercles, are yery rare. Nevertheless n"\\ and then :< 
specimen has been found for which this distinction has been claimed. 
In most of which the fracture has been of the nature of a simple fissure. 

Grosselin describes a case in which there were two fissures extending 
through tie- articular cartilage, and about one centimetre into the spongy 
structure. The joint contained half an ounce of blood ; death having 

i B • ■. Si( d. mdfi . -i >urn , -I'm'- 24, 1868, p. H". 



252 



FRACT1 i: ES OF Til K HUMERUS. 



afte 



accident, the exact character of which was 



two 



occurred 1 I 
not determined. 1 

Malgaigne has described a similar case, in which there wore 
fissures, one horizontal in its direction, and the oilier vertical. 2 

Gross refers toa case of single fissure of the head, which had become 
consolidate 

Howe speaks of a specimen in the Dupuytren museum in which about 
one-third of the head has been broken off and united. He also refers to 
another specimen in the same collect ion which Lenoit regarded as a 
fracture of the anatomical neck and which was ununited. 1 

Examples in which the fracture of the head is accompanied with a 
fracture of the anatomical neck, or of the tubercles, are much more fre- 
quently observed. 

Fractures of the Anatomical Neck sometimes follow, with a re- 
markable degree of accuracy, the line of the insertion of the capsular 
Ligament, being always, according to Robert Smith, within the interior 
<»r outer margin of this insertion. He calls them, therefore, intracap- 
sular. It is probable, however, since, as we shall presently see, bony 
union is not denied to certain supposed examples of this fracture — that 
the line of separation is not always, or generally, perhaps, completely 
within the insertion of the ligament, hut that it is in some degree extra- 
articular, if not extracapsular. 

Boyer says thai ho has seen several examples of this fracture, none of 
which, however, was accurately diagnosticated until after death. He 
observes that the specimens which have been fully 
recognized as intracapsular, would seem to show that 
the superior fragment contributes almost nothing to 
the process of repair, hut that, as in the case of 
intracapsular fractures of the neck of the femur, they 
are subjected to ;i process of partial absorption. He 
further illustrates the correctness of these conclusions, 
by reference to a case examined in the autopsy seven 
days after the accident, in which the head had already 
Buffered a remarkable diminution by the process of 
absorption. He quotes, also, two cases described by 
Reich el, in which union had taken place, and the 
exact line of fracture could not, therefore, be so 

accurately determined. 5 

Mr. Spence exhibited a specimen to the Medico- 
Chirurgical Society of Edinburgh, May 2, 1860. A 
man advanced in life, in consequence of a fall, sus- 
tained a fracture. He died at the end of four weeks, 
from appolexy. The fracture was found in the au- 
topsy to have passed "through the anatomical neck ; " 



Pig. 65 




the uriii- 



. 2. (In the text, vol. i. p. 526, only one fissure i.-, 



elin, Gurlt. 
7 Malgaigne 'e Atlas, pi. 1, 
described.) 

Q l atise "n Burg., l-t ed., vol. ii. p. 190. 

il (, / dec Bdp . L868, p 272. 

B • T til des Mai. Chir., Itb ed., L831, vol. iii. p. 199. 



FRACTURES OF THE HEAD AND ANATOMICAL NECK. 253 

that is, between the head and tuberosities, and within the capsular liga- 
ment. No union had taken place. 1 

Gibson, also, thinks that the fragment occasionally remains without 
becoming necrosed, or causing suppurative action, being gradually 
absorbed and changed in figure. He says that his museum contains 
three or four well-marked eases of this kind, in all of which the head 
has lost its spherical form, and is very much diminished, and rough and 
flattened next to the scapula. 2 Other cabinets are said to contain similar 
specimens. 

The displacements to which the upper fragment, or the head of the 
bone, is subject, are remarkable, and some of them do not seem to be 
satisfactorily explained. Frequently, indeed, its position is not sensibly 
disturbed, Inn at other times it is found impacted, or driven into the 
cancellous structure of the inferior fragment, in consequence of which 
one or both of the tubercles are frequently broken oft'. 

Robert Smith relates the following case as having afforded him his first 
opportunity of ascertaining by post-mortem examination the exact nature 
of this form of displacement : 

"A female, set. 47. was admitted into the Richmond Hospital, under 
the care of the late Dr. McDowell, for an injury to the humerus, the 
result of a fall upon the shoulder. Five years afterwards, the woman 
was again admitted, under the care of Mr. Adams, with an extracapsular 
fracture of the neck of the femur, one month after the occurrence ot 
which she died, in consequence of an attack of diarrhoea. 

•* The shoulder was of course carefully examined ; the arm was slightly 
shortened, the contour of the shoulder was not as full or round as that of 
its fellow, and the acromion process was more prominent than natural. 
Upon opening the capsular ligament, the head of the humerus was found 
to have been driven into the cancellated tissue of the shaft, between the 
tuberosities, so deeply as to be below the level of the summit of tin- 
greater tubercle: this process had been split off and displaced outward ; 
it formed an obtuse angle with the outer surface of the -haft of the 
bone." 3 

The description is accompanied with two excellent drawings "1" the 
specimen, showing the distance to which the superior fragment had pene- 
trated the inferior, and showing also complete union by bone. 

I believe, also, that in the following example there was a fracture at 
or near the anatomical neck, with impaction, anil splitting of the tuber- 
cles : 

January 12, 1858, a young num. aged about sixteen years, fell from 
a height in a gymnasium, Beverely injuring hi- left shoulder. I -aw 
him, with Dr. Boardman, soon after the accident, and found him com- 
plaining very much of the shoulder, which was somewhat swollen and 
tender/ He could not tell as how ho fell, nor could we discover any con- 
tusions by which to determine the point where the blow was received. 
All motion- of the Bhoulder-joint were painful : and there was ;i remark- 

, 6, p. 1140 
i . i i. ).. 279. 

3 R. Smith. F: ' pp. 191-8. 



25 1 FRACTU R Ks OF Til E HUM ERUS. 

able fulness in fronl of the joint, feeling like the head of the bone, yet 
nol Buch as is usually presenl in a forward luxation. To determine this 
more positively, however, the limb was manipulated as for the reduction 
of a dislocation. Once during the manipulation a feeble but distinct 
crepitus was detected; yel the position of the bone remained unchanged. 
The head was found to be in the socket, but the precise nature of the 
injury was not made out. 

Fifteen days later, when the swelling had completely subsided, a care- 
ful examination was again made by Dr. Boardman and myself, when we 
arrived at the conclusion that it was a fracture through the bicipital 
groove, and that the lesser tubercle was carried forwards half an inch or 
more from its fellow, while the head and the greater tubercle occupied 
their natural positions opposite the socket. The fragment projecting in 
front presented a sharp point, and could not be confounded with any 
swelling ol* the soft parts. There was a distinct space between the tuber- 
el--, into which the finger could be laid. No depression existed under 
the acromion process behind, but, on measurement, the head of this 
humerus was found to be half an inch wider in its antero-posterior diam- 
eter than the opposite. 

That tli is fracture was accompanied with impaction was rendered 
certain by the repeated and careful measurements of the length of the 
humerus, which constantly showed a shortening of half an inch. 

Under these circumstances union generally takes place; but it is 
usually accompanied with the formation of an irregular mass of osteo- 
phytes, which encircle the head like a coronet; presenting in this respect 
again a remarkable resemblance to extracapsular fractures of the neck 
of the femur. This ensheathing callus, as it may be called, is an out- 
growth from the inferior fragment, and it sometimes incloses the upper 
fragmenl as the case of a watch incloses the crystal, only in a manner 
much more irregular, thus retaining it steadily in its place, although very 
little direct union has occurred. The cancellous tissue, nevertheless, is 
occasionally found united completely by a new and intermediate bony 
tissue, and at other times by a fibrous tissue, or by both fibrous and 
bony tissue. 

In -nme cases ;i perfect false joint has been formed between the op- 
posing surfaces; while in a few unfortunate examples the head not only 
refuses to unite, hut by its presence, as we have already remarked, pro- 
duce- inflammation and suppuration, resulting in its final extrusion from 
the joint. 

At other times the upper fragment turns upon its own axis, and is 
found more or Less tilted or completely rotated in the socket; so that its 

cartilagii - or articulating surface rests upon the broken surface of the 

Lower fragment, and its own broken surface presents toward the glenoid 
cavity. 

Robert Smith has described a specimen of this kind which he removed 
from the body of B woman, aged forty, who many years previous to her 
death fell down a flight of stairs, and struck her shoulder with great 
violence against the edge of one of the step-. Whether she applied to 
a surgeon or not at the time of the accident, Mr. Smith was not able to 



FRACTURES OF THE HEAD AND ANATOMICAL NECK. 255 






■ 



M 






ascertain. After death the shoulder Fig. 66. Fig. 67 

looked somewhat as if there was a 
dislocation of the humerus into the 
axilla, there being a marked depres- 
sion under the acromion process, but 
the shaft of the humerus was drawn 
upwards and inwards toward the 
coracoid process. 

When the capsular ligament was 
opened, the head of the bone was 
found to have been broken from the 
shaft through the line of the ana- 
tomical neck, and to have completely 
turned upon itself; and the carti- 
laginous surface was actually driven 
one inch into the cancellated struc- 
ture of the shaft, so as to split off 
the lesser tubercle with a portion of 
the greater. Only one-half of the 
upper fragment was thus impacted, 
the other half projecting beyond the 
margin of the lower fragment. Be- 
tween the cartilaginous surface and 
the shaft no union had occurred ; 
but there was complete bony union 
between the upper and lower frag 
ments, beyond the limits of the car- 
tilage. 

The upper surface of the superior 
fragment rested in part against the 
inner half of the glenoid cavity and 
upon its inner margin, and in part it rested against the neck of the 
scapula in the direction of the coracoid process. 1 

Nelaton saw a similar specimen in the possession of M. Dubled, the 
revolution of the upper fragment being complete : but there was no lat- 
eral displacement, and the union had been accomplished in a manner 
similar to that which is seen after intracapsular, impacted fractures, 
without reversion. 2 

I have also been permitted to examine a specimen belonging to the 
late Dr. Charles II. Pope, of St. Louis, Mo., which seems to bave been 
broken not only through the line of the anatomical ueck, bu1 also through 
the surgical ueck. Both fragments are united by bone the lower frag- 
ment being carried in the direction of the coracoid process, while the 
upper fragment appears to bo reversed, 30 thai its articular surface i> 
directed toward the -haft, and its broken surface articulates with the 
glenoid cavity. The history of tin- specimen is unknown. 

Reverting to the histories of the several cases above referred to. in 



Dr. Pope's Specimen. 
Front view. Side view. 



ith, op. cit.. pp. 193-6. 
2 Nelaton, Element* de Pathol. Chirur., torn, prem., \>. ^C7 



2»6 F B A CTUBSS OF THE H U MERUS. 

which these extraordinary changes of position have taken place, ir would 

seem to admit of a doubt whether they were the direct results of the 
accidents which broke the bones, or whether they ensued indirectly, in 
consequence of a chronic arthritis following the accident, and the con- 
stant but long-continued use of the arm. and muscular contraction. 

There is another theory which, in my opinion, is capable of explain- 
ing most of the phenomena presented in some or all of those cases in 
which union of the fragments is claimed to have taken place, and which, 
if admitted, renders the supposition of a fracture unnecessary. It is, 
that in consequence of an injury, perhaps, but not of a fracture, chronic 
inflammation, softening and absorption have taken place, and that the 
changed position of the head is due to pressure alone, being acted upon 
by the muscles which surround the joint, and which act all the more 
vigorously because they partake also of the inflammation which has in- 
vaded the bone. This theory, which had already more than once sug- 
I itself to me. was very strongly confirmed by its having occupied 
the mind also of Dr. Neill, of Philadelphia, and who at his own instance 
stated to me that he believed this was their true explanation. AYe were, 
at the time, examining Dr. Pope's specimen, already alluded to, and on 
comparing it with a specimen of dislocation and partial absorption of the 
head of the humerus contained in Dr. XeuTs museum, the points of re- 
semblance were bo numerous and striking that we felt compelled to 
doubt whether Dr. Pope's specimen, together with those seen by Smith 
and Nelaton, did not belong to the same class with this of Xeill's. Other 
writers have reported similar cases. 

I do not mean to deny the possibility of bony union under these cir- 
cumstances, but only to suggest that such an occurrence would seem to 
he very improbable, and that its actual occurrence does not seem at 
present t<» be absolutely proved. If union by bone is improbable when 
the head of the femur is broken within the capsule, how much more 
improbable must it be when the head of the humerus is thus broken: in 
which latter case there is not even the poor supply of nutrition furnished 
to the head of the femur by the round ligament. 

In a case of fracture of the "cervix humeri within the capsular liga- 
ment." examined by Sir Astley Cooper, there was also a complete for- 
ward luxation of the head: but ligamentous union had occurred between 
the fragments. 1 

i 2. Fractures through the Tubercles. (Extracapsular; Non-impacted 
and Impacted.) 
I nder this division we intend to -peak of all fractures traversing the 
upper end of the humerus, and involving the tubercles: or of all those 
which occur between the anatomical neck on the one hand, and the epi- 
physeal junction, "i- surgical neck, on the other hand, and which may be 
more or Less oblique as well a- transverse. Fractures of the greater or 
lesser tubercles are of course excepted, since they are more properly 
longitudinal fractures, and do not completely traverse the diameter of the 
Nor do we intend to include those' fractures which occur at the 

1 Sir < n Dislocations, etc., p. 372. 



LONGITUDINAL FRACTURES OF HEAD AND NECK. 257 

epiphyseal junction : since, being below the principal insertion of those 
muscles which are attached to the tubercles, they present very peculiar 
and distinctive features, which will demand for them a separate classifi- 
cation and consideration. 

Causes, Pathology, and Results. — Fractures through the tubercles, 
like fractures through the anatomical neck, are the results generally of 
direct blows received upon the shoulder. They are not usually accom- 
panied with much lateral displacement at the point of fracture ; a cir- 
cumstance which finds a partial explanation in the fact that the line of 
fracture is through the insertions of the muscles converging upon the 
tubercles, and not entirely above or below them, so that they continue to 
act nearly equally upon both fragments ; but it is also sometimes due in 
a measure to impaction; the head being forced downwards toward the 
axilla, and upon the shaft, until it is made to ride upon its inner or axil- 
lary wall like a cap : the compact bony tissue of the shaft penetrating 
the reticular structure of the head. These fractures generally unite by 
bone ; yet more or less impairment of the motions of the limb results 
fr<»m the inflammation which occurs in and about the joint, or from the 
irregular deposits of callus in the vicinity of the fracture. 

^ 3. Longitudinal Fractures of the Head and Neck ; or Splitting" off of 
the Greater Tubercle. 

Causes, Pathology, Symptoms, and Results. — Mr. Guthrie seems to 
have been the first to call attention to this peculiar injury of the shoulder. 
In a lecture delivered in November, 1833, he described four cases which 
had come under his observation, and which he regarded as examples of 
separation of the small tuberosity, accompanied with more or less of the 
head, the fracture extending along a portion of the bicipital groove. 1 

Robert Smith, however, believes that it was the greater and not the 
lesser tuberosity which was thus detached in the cases mentioned by Mr. 
Guthrie, since the external signs were so nearly like those which were 
present in a woman seen by himself, and in whom an autopsy enabled 
him to verify his diagnosis. The following is the case as related by Mr. 
Smith : 

■• In July. 1*44. I was requested to examine the body of Julia Darby, 

aet. 80, who had died of chronic pulmonary disease. Upon entering the 

room, tie.- appearances of the left shoulder-joint at once attracted my 

attention, and struck me a- being different from those which attend the 

common Injuries of this articulation. 

■• The shoulder had lost, to a certain extent, it- natural rounded form ; 
the acromion process, although unusually prominent, did not projecl as 
much a- in cases of dislocation of the head of the humerus. The breadth 
of the articulation was greatly increased, and. upon pressing beneath the 
acromion, an osseous tumor could he distinctly felt, occupying the greater 
part of the glenoid cavity; it formed ;t prominence which was perceptible 
through the -oft parts; it moved along with the -haft of tin- humi 
but was manifestly not the head of the hone. 

1 Robert Smith. ]>. 181, from Loud. Bled, and Phys. Journal. 

17 



FRACTURES OF THE HUMERUS. 

•• A Becond and Larger tumor, presenting the rounded form of the head 
of the humerus, lay beneath the base of, and internal to, the coracoid 
process, and between the two the linger could be sunk into a deep sulcus, 
placed immediately below the coracoid process. The elbow could be 
brought into contacl with the side, and there was no appreciable altera- 
tion in the Length of the arm. 

k< Upon removing the soft parts, the head of the bone presented itself, 
lying partly beneath and partly internal to the coracoid process. The 
greater tuberosity, together with a very small portion of the outer part 
of the head of the bone, had been completely separated from the shaft 
of the humerus. This portion of the bone occupied the glenoid cavity, 
the head of the humerus having been drawn inwards so as to project 
upon the inner side of the coracoid process; it was still, however, con- 
tained within the capsular ligament. 

" The fracture traversed the upper part of the bicipital goove, which, 
in consequence of the displacement which the head of the bone had suf- 
fered, was situated exactly below the summit of the coracoid process. A 
new and shallow socket had been formed upon the costal surface of the 
neck of the scapula, below the root of the coracoid process, and the inner 
edge of the glenoid cavity corresponded to the posterior part of the sul- 
cus, which separated the head of the bone from the detached tuberosity. 
The Latter was united to the shaft only by ligament. 

•• The capsule had not been injured, but was thickened and enlarged, 
and the hone had been deposited in its tissue. The injury had evidently 
occurred many years before the death of the patient, but the history 
connected with it could not be precisely ascertained." 1 

Mr. Smith relates one other case, in the living subject, which he 
saw in connection with Mr. Adams, at the Richmond Hospital, and he 
adds that ••numerous" other living examples have fallen under his 
observation. 

Sir Astley Cooper has also published the particulars of a case of 
fracture of the greater tubercle, which was communicated to him by Mr. 
Herberl Mayo. 2 

The following I believe also to have been an example of this rare 
accident : 

.John Hill, at. 78. fell upon the sidewalk, striking upon his right 
shoulder. The physician to whom he was sent thought the humerus 
was dislocated, and directed him to the Buffalo Hospital of the Sisters 
of Charily, hut he did not apply for admission until eight days after, 
Oct. 1 k 1857, when Dr. Boardman and myself examined the limb care- 
fully. 

Although we placed him under the influence of chloroform, the diag- 
noais was uol satisfactorily made out. We inclined, however, to the 
opinion that it was a fracture of the greater tubercle. The antero- 
posterior diameter of the upper end of the bone was greatly increased; 
there was occasional distinct crepitus, but the limb was not shortened. 

1 Robert Smith, op. cit., p. 178. 

\ . • Dislocations and Fractures of the Joints. Edited by B. Cooper. 

i 



FRACTURES THROUGH THE SURGICAL XECK. 259 

Subsequently, the examinations were repeated many times, and the 
depression between the fragments becoming more palpable, the diagnosis 
was at length confirmed. 

No treatment was adopted, except confinement in h^d. and stimulating 
embrocations. Two months after the accident he still remained an inmate 
of the hospital, his shoulder being quite stiff, and the projection continu- 
ing in front. 

Dr. J. J. Charles, demonstrator of anatomy, Queen's College, Belfast. 
has reported a case with great care, which he believes to have been an 
example of this rare accident, and in which opinion I am disposed to 
concur. The man was 30 years old. and it is supposed that the middle 
of the head of the humerus was struck by the pole of a tram-car. Dr. 
Charles examined the patient fourteen months after the receipt of the 
injury: the breadth of the head of the humerus was greatly increased, 
there was a broad sulcus in the situation of the bicipital groove, and the 
humerus was shortened half an inch. The motions of his arm were very 
much limited, especially in abduction. 1 

Mr. Robert Smith thinks that when the displacement is considerable, 
the fragments generally unite by ligament, rather than by bone. 

s 4. Fractures through the Surgical Neck. (Including Separations 
at the Upper Epiphysis.) 

I have already defined the "surgical neck"' as all of that narrow 
portion commencing at the upper epiphysis and terminating at the 
insertion of the pectoralis major and latissimus dorsi. It seems proper, 
therefore, that we should include under this division both fractures and 
separations occurring at the epiphysis, especially since, owing to their 
anatomical relations, they are subject to the same displacements as frac- 
tures occurring half an inch or one inch lower down : the capsular mus- 
cles, with the exception of the teres minor, haying no more influence 
over the lower fragment when a separation occurs at the epiphysis, than 
when a separation occurs at any other point of the surgical neck. 

Separation at the Upper Epiphysis. — A brief description of* the plan 
of development of the humerus will enable the reader better to under- 
stand the occasional separation of the epiphysis, both at the upper and 
lower end- of the bone. 

The humerus is originally formed from -ev<-n cartilaginous centres, 
namely, one for the -haft, one for the head, one for the greater tuberosity, 
one for each epicondyle, and two for the lower, articulating end of the 
bone. At birth the shaft i- ossified in nearly it- whole length. Between 
the first and fourth years ossification commences in the several centres 
composing tie- apper end of the bone, and they coalesce by the end of 
the fifth year, so as to form ;i single epiphysis, which finally unite- with 
the shaft ;it about the twentieth year. At tie- lower end of the bone, 
ossification commences in the radial portion of the articular surface ;>t 
th<- end of two years, in the trochlear portion at twelve years, in the 
internal epicondyle at the fifth year, and in the external epicondyle at 

1 J. J 



260 



FB Ai'TT K ES OP Til k iitmbrus. 




I 



the thirteenth or fourteenth. At the sixteenth or seventeenth year all 
the centres are joined to each other, and to the shaft, except the inner 
epicondyle, which does not unite by bone until about the eighteenth 
year. It will be observed, therefore, that although 
ossification commences in the upper epiphysis 
first, it is the last to form bony union with the 
shaft. 

The following is a brief account of all the cases 
of separation at the upper epiphysis which have 
come under my notice : 

Cask 1. — In 1855, Mike Bovin, set. 13 months, 
fell sideways from his cradle, causing some injury 
to his arm near the shoulder. He was taken to an 
empiric, who called it a sprain, and applied lini- 
ments. Three weeks after the accident he was 
brought to me, and I found the arm hanging beside 
the body, with little or no power on the part of the 
child to move it. There was a slight depression 
below the acromion process, and considerable ten- 
derness about the joint ; but the shoulder was not 
swollen, nor had it been at any time. The line of 
the axis of the bone, as it hung by the side, was 
directed a little in front of the socket. 

On moving the elbow backwards and forwards, 
the upper end of the shaft moved in the opposite 
directions with great freedom, and could be dis- 
^m^^$P tinctly felt under the skin and muscles. This 

\ r ^ motion was accompanied with a slight sound, or sen- 

sation, a sensation not unlike the grating of broken 
bone, but much less rough. There was no short- 
ening, of the limb. When the elbow was carried a 
little forwards upon the chest, the fragments seemed to be restored to 
complete coaptation ; and of this I judged by the restoration of the line 
of the axis of the shaft to the centre of the socket, and by the complete 
disappearance of the depression under the point of the acromion process. 
I applied suitable dressings to retain the arm in this position ; but five 
months after the injury ^vas received the fragments had not united, and 
the child was still unable to lift the arm, although the forearm and hand 
retained their usual strength and freedom of motion. The same crepitus 
could occasionally he frit in the shoulder, and the same preternatural 
mobility. The shoulder ^vas at this time neither swollen nor tender. 

Case -. — Samuel Robuck, get. 13, fell through a hatchway, July 9, 
1 868, striking on hi- shoulder. He saw a regular physician within five 
hours after the injury was received, who said that the arm was dislo- 
cated : and on the following day, under the influence of chloroform, he 
tried to reduce it. The doctor thought he had succeeded, and he then 
applied bandages to keep it in place. At the end of two weeks the doctor 
declined, for reasons which are not known, to have any further care of 
the case, and the patienl consulted Dr. Voss, at the Dispensary. Dr. 
\ ' 38 detected the nature of the case, and sent him to me to confirm his 




Humerus, with epiphyses. 
From Gray. I 



FRACTURES THROUGH THE SURGICAL XECK. 261 

diagnosis. I found the upper end of the lower fragment projecting in 
front, and not united. The arm was shortened half an inch. I have 
not seen the patient since, and do not know the result. 

Case 3. — Joseph SneUback, an. 16, fell backwards down a flight of 
steps, striking upon his back and arm near the shoulder, May 10. 1868, 
causing a separation of the upper epiphysis of the left humerus. Dr. 

. of this city, now deceased, saw the patient within half an hour, 

and supposing that he had suffered a dislocation of the head of the hu- 
merus, he attempted to effect reduction with his heel in the axilla, and 
without anaesthetics. On the following day I found him in Ward 1<J at 
Bellevue. The house-surgeons were divided in opinion as to its char- 
acter, some at first believing it to be a dislocation : others, with myself. 
recognized it to be an epiphyseal separation. 

All efforts at replacement proving ineffectual, splints were applied by 
my direction, and on the loth of July the patient left the hospital with 
the fragments united, but overlapped at the point of fracture, the upper 
end of the lower fragment being in front of the upper fragment. The 
limb was shortened one inch, but its motions were free, and there was no 
reason to suppose that its utility was in any degree impaired. 

Case 4. — C. H.. an. 19, living in a neighboring town, in the delirium 
caused by fever, fell from a third-story window, May 12, 18(38. Two 
very intelligent and experienced physicians, who were called, thought the 
boy had received a fracture of the acromion process, accompanied with 
a dislocation of the head of the humerus, ami they attempted to reduce 
it. but without success. 

On the 2d of June following, three weeks after the receipt of the in- 
jury. I saw the patient in consultation with his physicians, and found a 
separation of the upper epiphysis of the humerus. The upper end of 
the lower fragment projected in front of the acromion process appear- 
ing a little above the level of the process, and covered only by the skin. 
No union had occurred between the two fragments. 

Case 5. — Fohn Davis, ®t. 18, fell about eight feet. September 2. 1873. 
Of the thro.' surgeons first called, Drs. II. and S. thought the boy had 
received a fracture: the third believed it to be a dislocation, and having 
placed the patient under the Influence of ether, attempts were made to 
re. luce it. The deformity not being relieved, I was added to the con- 
sultation. I found the shoulder a good deal swollen. The upper end 
of the lower fragment could be felt distinctly in fronl of the acromion 
process. At first, the surgeons informed me. the broken end seemed just 
under the skin and almost ready to be thrusl through, but the extension 
had made it retire somewhat. The end felt rough and serrated. While 
making extension 1 was able t<> detect a slight crepitus or click. Em- 
ploying Dugas'a test, 1 found the elbow would rest upon the front of the 
chest. In short, the diagnosis was complete, and Dr. 8., having taken 
charge of the case, applied one long splint, and ;i sling under the wrist, 
but not under tire elbow. The fragments bave united with very little 
deformity. 1 

This case was subsequently -'-en by Dr. Moore ;it one of my Bellevue 
clinic-, by whom my diagnosis was fully confirmed. 

1874. 



262 FRACTURES OF THE HUMERUS. 

CASH 6. — In Nov. L876, 1 found in my service, at Bellevue, Wm. 
Hague, set. l ( .'. who, from a fall on the sidewalk, had broken the humerus 
at it- upper epiphysis. Ee says, Dr. Erskine Mason reduced the frac- 
ture on the third day, and secured the limb with splints. He subse- 
quently tried to reduce it by Moore's method under ether, but was un- 
successful. The displacement was complete, and the entire upper end 
of the lower fragment could be distinctly felt. 

Robert Smith and Sir Astley Cooper both speak of it as a frequent 
accident in early life, but the recorded cases are very few. The case 
mentioned by Mr. Smith has been given very much at length, and, as a 
characteristic example, deserves to be repeated: 

" [hiring the early part of last year, a boy, eight years of age, was 
admitted to the Richmond Hospital, under the care of Dr. McDowell. 
. VI miit a week previous to his admission he had fallen upon the shoulder, 
and at once lost the power of using his arm. 

"It was at first sight evident that there did not exist any luxation of 
the head of the humerus, and it was equally obvious that the case was 
not an example of any of the ordinary fractures to which the neck of the 
bone is liable. There was no diminution of the natural rotundity of the 
shoulder, nor any unusual prominence of the acromion process; the head 
of the bone could be distinctly felt in the glenoid cavity, and it remained 
motionless when the arm was rotated; there was very little separation 
of the elbow from the side, but it was directed slightly backwards. 

••About three-quarters of an inch below the coracoid process there ex- 
isted a remarkable and abrupt projection, manifestly formed by the upper 
extremity of the shaft of the humerus, every motion imparted to which 
it followed. Its superior surface, which could be distinctly felt, was 
slightly convex, and its margin had nothing of the sharpness which the 
edge of a recently broken bone presents in ordinary fractures. 

••When this projecting portion of the bone was pushed outwards, so 
as to bring it in contact with the under surface of the head of the 
humerus (previously fixed as far as it was possible to do so), a crepitus 
was reduced by rotating the shaft of the bone. It did not, how r ever, 
resemble the ordinary crepitus of fracture, but it would be extremely 
difficult, by any description, to convey a clear idea of what the difference 
consisted in. 

u Fr<>m a careful consideration of the symptoms and appearances 
above mentioned (taking into account also the age of the patient), the 
diagnosis was formed, that the injury consisted in a separation of the 
superior epiphysis of the humerus from the shaft of the bone. Various 
mechanical contrivances were employed in this case, but all proved inef- 
fectual in maintaining the fragments in their proper relative position." 1 

Sir Astley Cooper has also briefly described one example, which oc- 
curred in a child ten years of age. 2 

According to Malgaigne, 3 Bertrandi found this condition in a child 
born dead, and Durocher reported a case, in which it was produced at 
birth by a midwife, who had hooked her finger into the armpit to expe- 
dite the delivery. 

1 Robert Smith, op. fit., p. 201. ' l Sir A. Cooper, op. cit., p. 382. 

5 Bertrandi, Durocher, Malgaigne, op. cit., t. i. p. 69. 



FRACTURES THROUGH THE SURGICAL NECK. 



263 



Prof. E. M. Moore, of Rochester, in a paper read before the American 
Medical Association, in 1874, ami published in the Transactions for that 
rear, has called attention to what he considers the true condition of the 
separated fragments in most of these cases, and to the proper remedy. 
He observes that the displacement is not usually complete; but that the 
upper end of the lower fragment is carried inwards to the distance of 
about one-fourth of its diameter, when it is arrested, by a convexity of 
the lower fragment becoming lodged in a natural concavity in the upper 
fragment. The upper fragment now becomes tilted by the action of the 
muscles, its internal margin ascending in the glenoid cavity, and its outer 
margin descending until it is arrested by the capsule. 



Fig. 69. 



Fig. 70. 





Upper epiphysis of 



From Moore.) Epiphyseal separation. (From Moore.) 



If. under these circumstances, the arm is carried forwards and upwards 
to the perpendicular line, the upper fragment or epiphysis will remain 
fixed, being hold fast by the capsule inserted into the outer and posterior 
margin of the head, while the lower fragment or diaphysis, aided by 
the natural action of the muscles, will move outwards and resume its 
original position. 

The correctness of this opinion he ha- verified by having in this man- 
ner effected the reduction with great ease, in three cases which have come 
under his observation. The patients were respectively Bix, fourteen, and 
sixteen years of air*-. 

In the first case the reduction was effected on the fourteenth day; in 
the second case, on the second day; and in the third, on the seventeenth 
day. In both of the latter, ineffectual attempts had been already made 
to reduce what was snpposed to be a dislocation. 

In order to maintain the reduction, it was only found necessary to 
bring the arm down while in a state of moderate extension, and to secure 
it beside the body with a Swinburne extension splint. Any of the forms 






FRACTURES OF THE HUMERUS. 



of dressing applicable to a fracture of the surgical neck would probably 
prove equally efficient. 

The observations made by Professor Moore seem to me exceedingly 
valuable; yet 1 do nol think it always happens that the separation is 
incomplete, nor does Professor Moore say that it is, but that was the 
condition in all the cases seen by him. Prof. Pooley, of Columbus, 
Ohio, reports a ruse occurring in a boy twelve years old, which he was 
unable to reduce by Moore's method. 1 Dr. 
Richmond reports another example in a 
young man nineteen years old successfully 
reduced by this method. 2 

In Cases 4, 5, and 6, reported by myself, 
the upper end of the lower fragment was 
above the level of the coracoid process, and 
seemed to be directly beneath the skin. These 
were probably examples of complete separa- 
tion ; but the remaining three presented the 
symptoms described as characteristic of the 
partial separation in Professor Moore's pa- 
per: the projection was less marked, and 
on a level with the coracoid process, or a 
little below it. 

In all my cases, except the first, the upper 
end of the lower fragment could be felt, not 
sharp or pointed, as in most examples of 
fracture of the surgical neck, but somewhat 
irregularly transverse, and when covered 
with the skin and muscle, might be easily mistaken, by the inexperienced, 
for the head of the bone. 

True Fracture at the Surgical Xecle. — It seems necessary, in order 
t<» a full understanding of the varying aspects under which this accident 
occurs, and in order to the establishment of the diagnosis, prognosis, and 
treatment, to relate a few illustrative examples. 

Case 1. Simple fracture^ never displaced ; union without deformity. 
— Alex. Balentine, a^t. 62; admitted to the Buffalo Hospital of the 
Sisters of Charity, J )<•<•. 19, 1851. He had fallen upon the sidewalk, 
striking upon his right arm. Dr. Johnson, of Buffalo, had reduced the 
fracture, and applied appropriate dressings. No union of the fragments 
had vet occurred ; bu1 as the surfaces were in apposition, it was only 
after considerable manipulation, and not until we bent the forearm upon 
the arm. and rotated the humerus by means of the forearm, that the 
crepitus became distinct, and gave unequivocal evidence of the existence 
of a fracture, and of its situation. 

The treatment, after admission, consisted in the application of one 
gutta-percha Bplint, accurately moulded, and extending from above the 
shoulder t<> below the elbow, and encircling one-half the circumference 
of the arm ; the splint being secured with the usual bandages, etc. 
The result i- a perfeel limb. 




Fracture of the surgical neck of 
the humerus. (From Gray.) 



1 Pooley, New York Journ. Med., February, 1875, p. 139. 
7 Richmond, New York Med. Journ., Nov. 1877. 



FRACTURES THROUGH THE SURGICAL NECK. 265 

Case 2. Simple fracture ; union, with displacement and deformity. 
■ — White, of Buffalo, aet. 12. fell fourteen feet, striking on the front and 
outside of the left shoulder. Dr. P., of Erie County, saw the lad within 
three hours (July UK 1853). He was brought to me on the fourth day 
after the accident. The upper part of the arm was then very much 
swollen. I found the arm dressed as for a fracture of the middle or 
lower third of the humerus. It was shortened one inch. The elbow 
was inclined backwards, and there was a remarkable projection in front 
of the joint, feeling like the head of the hone. The hand and arm were 
powerless. I suspected a dislocation of the head of the humerus for- 
wards: and. having administered chloroform, I attempted its reduction 
with my heel in the axilla. Whilst making extension. I felt a sudden 
sensation like the slipping of the bone into the socket, hut on examina- 
tion I found the projection continued as before. I then repeated the 
effort, with precisely the same result. 

I now applied an arm-sling, and directed leeches and cold evaporating 
lotion>. 

On the 25th. five days after the accident, it was examined by Drs. 
Mixer. McGregor, Joseph Smith, with myself. We still believed it was 
a dislocation, and. having administered chloroform, we again attempted 
its reduction. The same slipping sensation was produced as before, and 
the deformity was repeatedly made to disappear; but, on suspending the 
extension, it as often reappeared. 

The character of the accident was now made apparent, and we pro- 
ceeded at once to apply the splint and bandages suitable for a fracture 
of the surgical neck of the humerus, namely, a gutta-percha splint, ex- 
tending, on the outside, from the top of the shoulder to below the elbow, 
with an arm and body roller secured with flower paste. 

On the 31st. twelve days after the accident, Dr. Wilcox, Marine Sur- 
geon at Buffalo, saw the arm with me. The fragments were displaced 
same as when I first saw it. and the same as when no apparatus was 
applied. We examined it again carefully, and attempted to make the 
fragments remain in place, but we woe unable to do bo, except while 
holding them and making extension. 

August '.• (twenty-first day). I removed all the dressings. .Motion 
between the fragments had ceased, but the projection and shortening 
remained as before: now. also, the irregular projection- of the fractured 
bone- were more distinctly felt. The dressings were never reapplied. 
Three months later no change had occurred. He could carry the elbow 
forward- freely, a- well as backward.-, the motion- of the -boulder-joint 

being unimpaired. 

' L8E '■'>. Simple fracture, with displacement; resulting in deformity 
and non-union. — I,. B., of Lockport, set. 43, was thown from his horse 
in February, 1854, striking upon his right elbow. 

Dr. Maxwell, an experienced surgeon of Lockport, examined and 
dressed the fracture. Dr. Fassetl was present and assisted at ;i subse- 
quent dressing. Three surgeons, who examined the arm before Dr. M.. 
called it a dislocation. 

Twelve week- after the accident, Mr. B. called upon me. The right 
arm was shortened one inch ; the elbow hung off slightly from the body; 



266 FRACTURES OF THE HUMERUS. 

the upper end of the lower fragment was distinctly felt in front of the 
shoulder-joint, under the clavicle, feeling very much like the head of the 
bone. The fragments were not united, but they could be seized easily, 
and made to move separately and freely. He stated to me that he was 
subject to rheumatism, and especially in the shoulder and arm of the 
side injured. He wished to know whether it could not be "reset." 

Two years after. 1 found the bone still ununited. He was, however, 
able to write with that hand, having first lifted his arm with the other 
hand and laid it upon the table. 

Case 4. Simple fracture, probably impacted; resulting in deformity. — 
Wm. A., of Buffalo, ret. 15, fell backwards, June 4, 1855, striking on his 
back ami left shoulder. Dr. L. saw the case immediately, and, regard- 
ing it as a dislocation, attempted its reduction. He subsequently re- 
peated the attempt. I saw the patient with Dr. L. on the tenth day. 
The arm was shortened one inch and a half. The fragments were dis- 
placed forwards, projecting in front of and a little below the joint. As 
in Case 3, it might easily be mistaken for the head of the bone; but the 
difficulty of diagnosis had been very much lessened by the subsidence of 
the swelling. There was no motion between the fragments; nor could 
the deformity, by any manipulation or extension, be made to disappear. 
It was probably impacted. 

]NIareh 23, 1856, nearly ten months after the accident, I found the 
fragments remaining as when I first examined the limb, and the arm 
shortened one inch and a half. The elbow hung a very little back from 
the line of the body. The upper end of the lower fragment was lifted to 
within one inch of the head of the humerus ; the upper fragment having 
its head in the socket, with its lower end dowmvards and forwards. The 
arm was, however, in every respect as useful as before it was broken. 
It was equally strong, and he could raise his arm as high and move it in 
every direction as freely as he could the other. 

(\i uses. — Epiphyseal separations belong almost exclusively to the 
periods of youth and childhood, but true fractures at the surgical neck 
occur most often in adult life ; with the exception of one girl and two 
lads, aged, respectively, eleven, tw T elve, and fifteen years, all of the ex- 
ample- of this latter accident recorded by me (44) occurred in adults; 
yet Sir A. Cooper declares these fractures to be most common in in- 
fancy, while Malgaigne has never seen a case in a person under fifty- 
three years. 

Both epiphyseal separations and fractures at this point are occasioned, 
in mosl cases, by direct blows or falls upon the shoulder. Of thirty- 
one examples in which I find the cause recorded, twenty-two were from 
direct blows, eight from indirect blows, and one from muscular action, 
as in throwing a ball. Of the eight resulting from indirect blows, one 
was from ;i (all upon the hand, ^cvn by Desault, and seven were from 
fill- upon the elbow, of which two were seen by Desault, and five by 
myself. 

Pathology. — 1 have found the fragments sensibly displaced in twelve 
cases out of seventeen; a proportion much greater than has been ob- 
served by Malgaigne, who has only seen a displacement twice in more 
than twenty cases. It is certain, however, that complete or sensible 



FRACTURES THROUGH THE SURGICAL NECK. 267 

displacement is less common in this fracture than in most other fractures, 
the broken ends being retained in place, probably, by the long tendon of 
the biceps, and the long head of the triceps. 

As to the direction of the displacement. I have generally found the 
upper end of the lower fragment drawn forwards and upwards toward 
the coracoid process: in one of which examples the upper fragment 
plainly followed in the same direction. Sir Astley Cooper declares that 
with infants this direction is constant, and in museum specimens I have 
seen but one exception. In the specimens of fracture of the surgical 
neek. with also displacement of the head, belonging to Dr. Pope, this 
direction of the fragments is plainly seen, as also in one of the specimens 
belonging to Dr. Neill, of the Pennsylvania Medical College, where the 
lower fragment almost reaches the coracoid process, and in a specimen 
contained in one of the cabinets of the University of Pennsylvania, where 
the upper end of the lower fragment has become united by bone to the 
coracoid process. 

The only exception which I have met with is in the possession of Dr. 
Neill. In this example the two ends are tilted toward the axilla. I am 
compelled, therefore, to doubt the accuracy of Malgaigne's observations, 
who thinks he has seen the lower fragment most often drawn toward the 
axilla, as well as the observations of those who think that the upper frag- 
ment is generally displaced outwards ; yet, no doubt, they do sometimes 
assume this position. Desault has seen them both thrown backwards ; 
while Dupuytren, Paletta, and others have seen them pushed outwards: 
and I have in my collection the copy of a specimen in which both frag- 
ments are drawn outwards, but the lower fragment is to the inner side 
of the upper. 

When the fracture occurs at or near the epiphysis, it is sometimes ac- 
companied with impaction, of the same character as we have already 
described when speaking of fractures through the tubercles. Robert 
Smith has given, in his treatise, an engraving intended to illustrate the 
relative position of the fragments in extracapsular impacted fractures, 
and the line of separation very nearly corresponds to the line of junction 
of the epiphysis with the shaft. 

But in a majority of cases no impaction occurs. Dr. Charles A. Pope, 
of St. Louis. Mo., has two specimens of this kind, in which no union has 
taken place, nor i< there any evidence that impaction had ever occurred. 
In one case the line of fracture commences ;it the junction of the head 
with the shaft, and extends thence irregularly across to a point half an 
inch below the greater tuberosity. In the second specimen the fracture 
commences ^ the <ame point, and terminates three-quarters of an inch 
below the greater tuberosity. In relation to these bone-. Dr. Pope 
remarks: "These are not cases of detachment of 1 1 m- epiphyses, as the 
boie- are evidently those of adults, and there is, ;it their lower extremi- 
ties above the condyles, no trace of an epiphyseal lino." 

Remits. — Sixteen of the examples of fracture of the surgical neci 
recorded by me are known to have resulted in perfed limbs; thai is to 
say, there is no displacement, overlapping, or shortening, and the patients 
have recovered the free use of the limb-. These were all, probably, 
examples in which no displacement over occurred. Of the remainder, 



268 PBAOTURES OF THE III'MERUS. 

all, bo far as I have been able to determine, have united with some dis- 
placement; bul in nearly all the functions .of the limb have been fully 
or almost fully restored. The only exception I can recall is the single 
one in which n<> bony union ever took place (Case 3, Report on Def. 
after Frac). 

Symptoms, or Differential Diagnosis of Accidents about the Shoulder- 
joint. — No place could be more appropriate than this to call attention 
to the difficulty of diagnosis in the case of accidents about the shoulder- 
joint, a difficulty which surgeons have constantly recognized, and which 
has sometimes rendered diagnosis impossible. 

Le1 us first study the ordinary signs of a dislocation at the shoulder- 
joint, regarding this as the type with which the other accidents are to 
he compared. 

a. Signs of a Dislocation. (Cause, generally a fall upon the elbow 
or hand, yet not very unfrequently a direct blow.) 

1. Preternatural immobility. 

± Absence of crepitus. 

•'). When the bone is brought to its place, it will usually remain with- 
out the employment of force. 

These three are common signs, which apply to any other joint as well 
as to the shoulder. 

4. Inability to place the hand upon the opposite shoulder, or to have 
it placed there by an assistant, while at the same time the elbow touches 
the breast. This is a sign common to all of the dislocations of the 
shoulder. 1 

The following are special signs, or such as belong only to particular 
dislocations of the shoulder. 

0. Depression under the acromion process; always greatest under- 
neath the outer extremity, but more or less in front or behind, according 
a- the dislocation may be into the axilla, forwards or backwards. 

'*». Round, smooth head of the bone sometimes felt in its new situa- 
tion. ;md very plainly removed from its socket; moving with the shaft. 
Absence of the head of the bone from the socket. 

7. Elbow carried outwards, and in certain cases forwards or back- 
ward^ and not easily pressed to the side of the body. 

v . Arm lengthened in the subcoracoid and subglenoid dislocations; 
and only shortened in the subclavicular and subspinous. Occasionally, 
in <>ld case-, the head of the humerus, leaving the subglenoid position, 
becomes subscapular, being placed upon the centre of the scapula, and 
the arm is shortened. 

b. Signs of << "Fracture of the Xeck of the Scapula. (Cause, gen- 
erally a direct blow: exceedingly rare.) 

1 . Preternatural mobility. 

-. Crepitus, generally detected by placing the finger on the coracoid 
process, and the opposite hand upon the back of the scapula, while the 
head of the humerus is pushed outwards and rotated. 

3. When reduced, it will not remain in place. 

1 Reporl "it ;i New Principle of Diagnosis in Dislocations of the Shoulder-joint, by 
L. A. Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Amer. 
Med. Assoc, vol. \. i> 17">. 






DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 269 

4. The hand may generally, bur with difficulty, be placed upon the 

opposite shoulder, with the elbow resting upon the front oi' the chest. 

5. Depression under the acromion process, but not so marked as in 
dislocation. 

6. Head of the bone may be felt in the axilla, but less distinctly than 
in dislocation. Never much forwards or backward.-. Head of the bdne 
moves with the shaft. Head of the bone not to be felt under the acro- 
mion process, although it has not left its socket. 

7. Elbow carried a little outwards, but not so much as in dislocation. 
Easily brought against the side of the body. 

N . Arm lengthened. 

9. The coracoid process carried a little toward the sternum, and 
downwards. 

10. Pressing upon the coracoid process, it is found to be movable, 
and it is also observed that it obeys the motions of the arm. 

c. Signs of a Fracture of the Lower or Anterior Lip of the Glenoid 
Cavity. Xot yet fully determined. 

d. Signs < : r ' Fracture of the Anatomical Neck of the Humerus. 
Intracapsular. {Cause, a direct blow: generally opening to the joint, 
but not alwi 

1. Mobility not increased, nor diminished. 

'2. Crepitus, generally discovered by pressing up the head of the 
bone into its socket and rotating: or. when the tubercles are also 
broken, by grasping the tubercles and rotating the arm. 

3. Fragments not generally displaced. 

4. The hand can lie placed easily upon the opposite shoulder, with the 
elbow against the front of the chest. 

•"). Very slight, if any. depression under the acromion pi 

• I. Head of the bone generally in its socket, but not felt bo distinctly 
a- before the fracture. 

7. Elbow falls easily against the side of the body, or is easily placed 
there. 

v . Arm not lengthened, nor appreciably shortened, unless the head 
be driven so much into the body a- to separate the tubercles. 

9. In this latter case there arc present also the signs of fracture of 
the tubercles. 

Signs ofFractun of the Humerus through, the Tubercles. Extra- 
capsular. I ( ''">.<<. direct Won 3. 

The sign- which characterize this accidenl are more obscure than in 
either ther shoulder accidents. They are mostly negative, and 

will not generally be determined positively except in the autopsy. 

1. Generally/ there is neither marked mobility nor immobility, ex- 
cept what immobility may be due t<» a contraction of the muscles. 

2. Crepitus, discovered, but not so easily as in intracapsular frac- 
tures, by rotating the arm while the tubercles are grasped firmly. 

If displacement exists, tie- fragment* isily kept 

in place when once reduced. 

4. The hand can be placed upon the opposite shoulder, with the 
elbow against the front ,,f the < 

."",. No depression under the acromion pr< 



270 FRACTURES OF THE HUMERUS. 

6. Head of the bone in its socket, and moving with the shaft, when, 
as is usually the rase, it is impacted. 

7. Kn»<,\\ hangs againsl the side of the body. 

8. Arm shortened when impacted, but not much. 

f. Si,/, is of a Longitudinal Fracture of the Head and Neck, or 
splitting off of the Cheater Tubercle, (Cause, direct blow upon the 
front of the shoulder.) 

1. Mobility of the limb natural. 

2. Crepitus; elicited especially by grasping the tubercles and rotat- 
ing the arm, or by carrying it up and back and then rotating. 

3. When reduced, the fragments will not remain in place. 

4. The hand can be placed upon the opposite shoulder, while the 
ell H iw rests against the front of the chest. 

5. Some depression under the acromion process. 

6. A smooth bony projection directly underneath the coracoid process, 
or close upon its inner or outer side, moving with the shaft The head 
of the hone cannot be felt in the socket, yet the space under the acro- 
mion is not entirely unoccupied. 

7. Generally, but not always, the elbow hangs against the side. 
Sometimes it inclines a little backwards. It can always be easily 
brought to the side. 

v . Ann generally neither lengthened nor shortened. 

'- 1 . A remarkable increase in the antero-posterior diameter of the upper 
end of the bone. 

10. A deep vertical sulcus between the tubercles, corresponding with 
the upper part of the bicipital groove. 

g. Signs of a Fracture through the Surgical Neck. {Cause, gen- 
erally direct blows, but in old people frequently caused by a fall upon 
the elbow.) 

1. Preternatural mobility often, but not constantly, present. 

2. Crepitus, produced easily when there is no impaction, or when the 
displacement is not complete, but with difficulty when impaction exists 
or the displacement is complete. 

3. Wheo once the fragments have been displaced, it is exceedingly 
difficult ever afterward to maintain them in place. 

4. The hand can he easily placed upon the opposite shoulder, while 
the elbow rests against the front of the chest. 

5. A Blight depression below the acromion, not immediately under- 
neath its extremity, but an inch or more below. 

'J. Bead of the bone in the socket, and moving with the shaft when 
impacted, but not moving with the shaft when not impacted. The upper 
end of the lower fragment being often felt distinctly pressing upwards 
toward the coracoid process; its broken extremity being easily dis- 
tinguished by its irregularity from the head of the bone. 

7. Elbow hanging against the side when the fragments are not dis- 
placed, but away from the Bide when displacement exists. 

8. Length of arm unchanged unless the fragments are impacted or 
overlapped; or both fragments are much tilted inwards. If the frag- 
mente are completely displaced, the arm is shortened. 

h. Signs of a Separation of the Epiphysis, {Cause, direct blows.) 
1. Preternatural mobility. 



DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. l!71 

-. Feeble crepitus: less rough than the crepitus produced when 
broken bones are rubbed against each other. 

B. Fragments replaced are not easily maintained in place, unless the 
reduction has been effected by Moore's method. 

4. Same as in preceding variety of fracture. 

5. The depression is not immediately under the acromion, yet higher 
than in most fractures of the surgical neck, perhaps one inch below the 
acromion process. 

6. Head of the bone in its socket, and not moving with the shaft. 
Upper end of lower fragment projecting in front, when displacement 
exists, and feeling less sharp and angular than in case of a broken bone: 
indeed, being slightly convex and rather smooth, it may easily be mis- 
taken for the head of the bone. 

7. Same as preceding variety. 

8. Length of arm not changed unless the fragments are overlapped. 
or both fragments are tilted upon each other. When the fragments are 
overlapped, the ami is shortened. 

9. This accident is peculiar to the young. It can seldom occur after 
the twentieth year. 

There are other accidents about the shoulder-joint, such as a patho- 
logical partial luxation of the humerus, dislocation of the tendon of the 
biceps, etc.. which might possibly be confounded with fractures, but the 
consideration of which I shall reserve for another time. 

My readers will here permit me to quote at length a portion of a clin- 
ical lecture delivered by myself at Bellevue Hospital, in 1875. calling 
attention to two new differential signs: 1 

••Examples of errors of diagnosis in the case of injuries involving the 
shoulder-joint are very frequent. My personal experience furnishes me 
with probably forty or fifty cases in which the head of the humerus has 
been supposed to be dislocated when it was not: or in which it lias been 
supposed to be broken when it was not. For this reason it is important 
that we be informed of every known means of diagnosis: and to those 
which are already known and published I will now add two more, of 
which we will be able pretty often to avail ourselves. 

••When the head of the humerus i- in it> socket it projects outward-, 
beyond the extremity of the acromion process, from half an inch to an 
inch: varying more or less according to the age and size of the person. 
It projects also in front of the acromion process ;i little, but not at all 
behind. 

••In case of a dislocation, in whatever direction the bead of the hu- 
merus is displaced, there can be no bony projection outwards beyond 
the acromion process. This fact may be ascertained always, unless 
there i- very great swelling of the -oft parte over the point of the -boul- 
der: but it will be necessary that we should be familiar with the Datura! 
outline of the acromion process, and tin- is a study which medical men 
too much n<-_ r b-i-t. namely, the study of the natural form of the surface 
of the body, or what I call 'Superficial Anatomy.' We must learn to 

1 Two Xew Different : - _ f the Should <ture 

by the author at Belle v; II M 27 375, p. 220. 



272 FRACTURES OF THE HUMERUS. 

know where is the outer end of the clavicle, where is the outer end of 
the acromion process, and where is the coracoid process, if we expect to 
determine the existence or absence of a dislocation of the shoulder. This 
exercise you can pursue in your bedrooms, on your own persons or on 
the persons of others. With a camel's-hair pencil, moistened with the 
tincture <>\ iodine, you can mark out upon the skin the line of the clavi- 
cle, acromion process, spine of the scapula, etc. In attempting this for 
the first time you will probable find that there is much to learn that you 
did not know before, however thoroughly you have studied the anatomy 
of the shoulder in the dissecting-room, when the skin is removed. The 
same applies to all the other joints of the body; and now you will under- 
stand why some men, perhaps wholly ignorant of anatomy as it is usually 
taught, hut familiar by long practice with superficial anatomy, will re- 
cognize in a moment the nature of a joint injury, which you may fail 
after a very careful examination to detect. 

" Let us return to the consideration of the two special signs of shoulder- 
joint dislocation (liable to only one exception, as I shall hereafter explain), 
which I wish to add to those already given by surgical writers. 

-First. While the head of the humerus remains in its socket, if a rule 
be laid upon the outside of the arm from the shoulder to the elbow, it 
will not touch the acromion process, but will be distant from it at least 
half an inch, generally one inch or more. On the other hand, if the 
hone i> removed from the socket, in whatever direction it may be dis- 
placed, whether forwards, downwards, or backwards, unless the shoulder 
is much swollen, the rule, placed in the manner above stated, will touch 
the acromion process. 

"Second. If, standing behind the patient (in case of the right shoul- • 
der), the thumb and forefinger of the left hand are made to grasp the top 
<»f the shoulder in such a manner that the interdigital commissure shall 
rest upon the acromion process, just outside of the acromioclavicular 
articulation: and if then the finger and thumb are dropped perpendicu- 
larly, the tip of the finger will (in case the head of the humerus is not 
di<l<>car<-d) resl upon the centre of the round upper extremity of the 
humerus, as it projects in front of the acromion process, while the end of 
the thumb will rest upon the head of the humerus behind; but the head 
will he felt indistinctly by the thumb, for the reason that instead of pro- 
jecting ;i- it doe- in front, it actually recedes a little beneath the acro- 
mion process. Up to this moment the surgeon may entertain some 
doubt whether lie is actually grasping with his thumb and finger the 
head of the hone: hut if he now moves the elbow of the injured limb 
forwards, so ;i- t<> carry the head of the humerus backwards in its 
socket, lie will feel it press strongly upon the thumb, and this will be 
conclusive. IT a dislocation exists, the head of the bone cannot be felt 
in this situation, and by the thumb thus placed. 

"As we have -aid before, both of these differential signs, in their 
application to shoulder-joint injuries, are liable to one exception. The 
phenomena would he the same, bo far as these two signs are concerned, 
whether there was a dislocation of the head of the humerus, or a frac- 
ture with displacement of the neck of the scapula. The latter accident 
must, therefore, be first excluded by a careful application of the rules of 



FRACTURES OF THE ANATOMICAL NECK. 273 

diagnosis given in our treatises upon surgery: but that upon which you 
can most safely rely is the relative infrequency of the two accidents. 
It is doubtful whether a long and active surgical practice will ever fur- 
nish you with an example of fracture of the neck of the scapula, while 
you will meet with a great many eases of dislocation of the shoulder." 

Treatment. — I have already spoken of the treatment of fractures of 
the neck of the scapula, and my remarks will now be confined to frac- 
tures of the upper end of the humerus. 

Fractures of the Anatomical Neck; Intracapsular. — As has already 
been stated, these are generally compound fractures, and. from the ex- 
tent of the injury, often demand resection, or amputation of the entire 
arm. If an effort is made to save the arm. splints will not be applied. 
and the treatment will have little or no reference to the existence of a 
fracture : it will be directed only to the reduction or prevention of the 
inflammation, etc. 

Simple fracture of the anatomical neck, if not entirely within the 
capsule, without any external wound communicating with the joint, and 
accompanied, as it is sometimes, with impaction, may unite, or the upper 
fragment may become incased in the lower. 

It is not proper in such cases to employ great violence for the purpose 
of detecting crepitus, lest the fragments should become displaced; and 
if the arm should be found to be a little shortened, it must not be ex- 
tended, with a view to overcoming the shortening, since upon the impac- 
tion probably depend, in a great measure, the chances of union. 

The elbow and forearm may be suspended in a sling, while the arm 
- gently supported against the side, merely to insure quietude. No 
splints are necessary or useful. 

Treatment of Fractures through tin- Tubercles (Extracapsular); Non- 
impacted 'i ml Impacted. — In these cases, also, the fragments being 
seldom displaced, very little, if any. mechanical treatment is demanded. 
A -ling is all that is usually required. If. however, on accounl of dis- 
placement of the fragment, a splint i> thought necessary, it must be ap- 
plied in the manner hereafter to be directed in cases of fractures of the 
Burgical ne<-k. 

If impaction, with shortening, exists, the same remarks are applicable 
here a- in intracapsular impacted fracture.-, namely, thai we ought not 
t<» rotate the limb much, nor violently, in order to discover crepitus, nor 
make extension with the view of overcoming the shortening, since the 
fragments unite more promptly and certainly when the impaction re- 
mains, and it- continuance in no way damages tin- usefulness of the 
limb. 

y fudinal Fracture of the fl< ad and A of a 

iration of the Greater Tubercle. — In the only instance which I have 
gnized as ;i fracture of Hi.- greater tubercle, and already referred to, 
the displacement was moderate, and could not be overcome either by 
change of position or by pressure with extension. The patienl was, 
therefore, merely laid upon his back in bed. No dressings of any kind 
were employed, and the fragments seemed to unite promptly, and with 
no increase in the displace! 

If the displacement i- originally more considerable, attempts ought 



274 FRACTURES OF THE HUMERUS. 

to be made to reduce tlio fragments, by extension and abduction 
of the arm, with direct pressure; yet they will not generally prove 
completely successful, nor will it be found easy to retain them when 

reduced. 

Mr. Mayo treated a fracture of this character, which occurred in a 
man of sixty years <>f* age, with a figure-of-8 bandage, and a sling, with 
a lathe splint od the other side of the humerus, the upper part of which 
w;i> made t<> bear on the fragments, by uniting the upper part of the 
circular arm roller to the figure-of-8 bandage. "The fracture united 
favorably," he says, hut we presume that he does not mean to affirm 
that it united without any degree of displacement; a result which prob- 
ably ought never to be expected. Mr. Mayo adds, however, that "for 
a long time the patient had some difficulty in carrying the arm back- 
wards."" 1 

Treatment of Fractures of the Surgical Neck, including Separations 
<it tin- h)>/'/'////sis. — We have already considered the value of Moore's 
method of reduction in cases of incomplete epiphyseal separations of 
the upper end of the humerus; but the reduction having been accom- 
plished, I see no reason to suppose that the indications of treatment can 
essentially vary in separations at the epiphysis from those in true frac- 
tures through any part of the surgical neck, since the relative action of 
the muscles remains the same, and the direction of the displacement is 
generally the same. My remarks, therefore, upon this point may be 
considered as equally applicable to fractures and epiphysary separations. 

In a considerable proportion of these cases not much displacement of 
either fragment takes place, and consequently we have only to apply 
such moderate retentive means as will insure quiet. Indeed, under such 
circumstances we might not hesitate to adopt the posture treatment 
practised by Dupuytren in two cases, both of which terminated favor- 
ably. The treatment consisted in placing the arm, semi-flexed, on a 
pillow, the pillow being arranged so as to form a pyramid, the summit 
of which was lodged in the axilla, while the elbow was secured to the 
side "I" the body by a bandage. 2 

Unhappily, however, as we have seen, this condition is not always 
presenl ; the most frequent form of displacement being that in which the 
lower fragmenl is drawn upwards and inwards, or toward the coracoid 
process. 

In such cases it will require, often, no little perseverance and skill to 
effect reduction, if it is not found to be actually impossible, and still 
more to retain the bones in place when once reduced. Indeed, it is 
proper to say that a complete reduction is seldom accomplished and per- 
manently maintained, owing, probably, to the advantageous action of 
the muscles which tend to produce the displacement, and in part also to 
the difficulty of applying any apparatus or dressing which shall act effi- 
ciently upon the fragments. 

Sir Astley Cooper recommends for this accident a couple of splints, to 
be placed one in front of and one behind the shoulder, an axillary pad, 

1 B. Cooper'a edition of Sir A. Cooper on Dislocations, etc., American edition, 
Dupuytren "a Bones, Sydenham edition, p. 99. 



TREATMENT OF FRACTURES OF SURGICAL NECK. 



275 



a clavicular bandage, and a sling: the sling being made to suspend only 
the wrist, and not the elbow, since he had observed that when the elbow 
was lifted the upper end of the shaft was inclined to fall forwards. 

Mr. Tyrrel informed Mr. Cooper that in a similar case he bad found 
the bone best maintained in its natural position by its being raised and 
supported at right angles with the side, by a rectangular splint, a part 
of which rested against the side, while the arm reposed upon the other 
part : and until he had made use of this plan, he could not succeed in 
removing the deformity, or in keeping the bone in its place. 

The following is the plan which I have myself generally preferred: 

Two splints are prepared, made of felt, gutta percha, gum-shellac 
cloth, or leather. The two latter are the most economical, generally 
most easily obtained, and answer the purpose as well as either of the 
others. The leather to be employed should be sole leather, of medium 
thickness, ami hemlock tanned. (See General Treatment of Fractures, 
Chapter VI.) 

The " long" splint must be long enough to extend from the top of the 
acromion process to a point just above the external condyle. The form of 
the leather splint, before it is moulded, is represented in the accompanying 
woodcut. Fig. 72. It is then to be bevelled or thinned along its edges 



Fig. 72. 



AA\ 



Fig. 73. 



Fig. 74. 



Plan of author'- l<>n^ 
leather arm-splint. 



Long leather Bplinl 
at top, and in ?h 



Short splint. 



by shaving ;i thin ribbon from the margins on the side which is to be laid 
against tin- arm; ;i few holes are to be made with a brad-awl on the 
margins of the V-shaped section Mt the upper end. Having Boaked the 
splint in water ;i few minutes, or until it i- rendered slightly flexible, it 
lied up from its tw.» sides until it baa flic Datura] curve of the eir- 
cumference of the arm. li' it is wot too much it \vill yield under the 
pressure of the bandages, and this i- not desirable. It ought t" be 
straight, or Dearly so, in it- bngitudinal a - ;>t the top. where it 

embraces the end of the shoulder; and it should bo inflexible when 
applied, the splint touching the arm firmly only over the bead and tuber- 
osities, and along the lowor portion of the humerus. The V-shaped 



276 FRACTURES OF THE HUMERUS. 

section ;it the top of the splint is then closed with strong linen, or shoe- 
maker's thread : and in order to give it a more regular curve, and to 
render it smooth, it may be hammered. 

Some of the splints which surgeons prepare, in imitation of this gen- 
eral plan, extend too far upon the shoulder, and are liable to be disturbed 
in the motions of the neck or of the arm. It is only necessary that the 
splint should embrace the shoulder sufficiently to prevent its sliding 
down. The splint will now be completed by inclosing it in a loose flan- 
nel sack, stitched on the outside. If the arm is swollen and tender, or 
the skin very delicate, a thin sheet of cotton wadding should be laid 
between the cover and splint. 

The -'short'' splint made of leather, or gum-shellac cloth — binders' 
board will answer equally well — carefully trimmed, and covered with 
flannel cloth, must have sufficient length to extend from the free margin 
of the axilla to the internal condyle, taking care that it shall not touch 
either. The purpose of this splint is not to support the fragments, for it 
is apparent that it cannot extend so high, even, as the point of fracture; 
but it is solely to protect the delicate skin beneath the arm from the 
bandages, which are apt to form cords and cause excoriations. In this 
point of view it is of great importance, and cannot properly be omitted. 

The splints being laid upon the arm, and while extension and counter- 
extension are maintained by assistants, for the purpose of restoring the 
fragments to position if possible, the surgeon will apply a roller, in- 
closing the splints, from the elbow to the axillary margins. This roller 
must be carefully stitched to the covers of both splints. A second roller 
is then carried from the top of the long splint to the opposite axilla, and 
by several successive turns the upper end of the splint and the shoulder 
are completely covered in. This is also to be made fast to the cover of 
the long splint, by stitches. Finally, a third roller is made to' inclose 
both the body and the low r er portion of the arm; and the forearm is 
xruied at ;i right angle with the arm by a sling, looped under the fore- 
arm. It is important that the sling shall not embrace the elbow, since 
it will, if thus applied, tend to displace the fragments and drive them 
past each other. 

The bandage or roller hitherto applied by surgeons to the hand and 
forearm, when dressing a broken humerus, is wholly unnecessary and 
often -i source of annoyance. The roller inclosing the arm and splints 
will seldom give rise to serious congestion or swelling of the forearm 
and hand unless it is applied too tightly; and when swelling does occur 
it will be promptly relieved by a few hours' or days' confinement in the 
horizontal position. The most serious objection, however, to the roller 
applied to the hand and forearm, is not that it is unnecessary, but that 
it is, in mos1 cases, injurious. It is exceedingly liable to become dis- 
arranged, especially if the patient is permitted to move the arm at the 
elbow-joint ; and in mosl cases it will be soon found, by its unequal 
pressure, to cause those congestions and swellings which it was designed 
to prevent. Perhaps it will be sufficient for me to say that for many 
years I have rejected this bandage altogether in all fractures of the 
humerus, and that no harm has ever come of the practice. 

It will be readily seen that the first roller performs the most important 



SHAFT BELOW THE SURGICAL NECK. '277 

function in this dressing. The long outer splint being firm and unyield- 
ing, and being supported above by the projection of the head of the 
humerus, the first roller draws the upper end of the lower fragment out- 
wards, and thus, as far as possible, accomplishes its readjustment. The 
upper fragment is always beyond our control. The second roller is not 
of much use. inasmuch as it soon becomes loose ; and in any event it 
can only hold the to}) of the splint a little more firmly against the head 
of the humerus. I occasionally omit it. The third roller insures 
quietude to the arm, in the best position, namely, beside the body. 

When the patient is standing or sitting, the forearm needs to be sus- 
pended in the sling: but when reclining, the forearm may, if the patient 
chooses, be extended. If the entire dressing is well stitched it is not 
much liable to disarrangement, and may be worn two or three weeks at a 
time without removal; but from time to time, as the swelling subsides 
or the muscles atrophy, the bandages may need to be tightened by over- 
stitching, or by supplementary rollers. 

I have been thus minute in my description of this dressing, because 
its value depends upon the care with which the details are carried out; 
and because, essentially, the same dressing is used by me in all fractures 
of the humerus occurring through its upper or middle thirds ; moreover, 
I do not wish to be held responsible, in any case, for bad results when 
dressings are applied in an imperfect or slovenly manner. 

If union take< place without overlapping, of course the arm is not 
maimed by the fracture: but even when the union occurs with consid- 
erable overlapping, the usefulness of the arm is seldom impaired. 

In case the functions of the arm are seriously impaired in consequence 
of the displacement of the fragments, and many months or years have 
elapsed without any improvement, a result which, to say the least, is 
very uncommon, the surgeon might consider the propriety of surgical 
interference after the method of Lindner; who cut down and reduced 
the fracture, with the result of only a partial reduction, with fibrous 
union, but it is added, that the functions of the arm were restored. It 
is my opinion, however, that the discreet surgeon will not find satisfac- 
tory reasons for such a procedure. 1 

^ 5. Shaft, below the Surgical Neck and above the Base of the Condyles. 

Causes. — In ;i record of 36 cases in which the cause of the fracture 
is stated, I find this portion of the >haft broken from direct violence 
21 times; from indirect blows, the concussion being received upon the 
elbow, 9 times; twice it was a consequence of tertiary lues, once it 
occurred during birth, and three time- in the same patient it has been 
broken from muscular action alone, each consecutive fracture occurring 
at a different point. The records of surgery furnish many examples oi 
fracture of the shaft of the humerus from muscular action, ;i- in throw- 
ing ;i stone or snowball ; but the most singular examples are those in 
which the bone has been broken in ;i trial of strength between two 
persons, by grasping the hands palm to palm, with the elbows resting 

1 Lindner, Centralblatt fur Chi r., 1881, April 16. 



FRACTURES OF THE HUMERUS. 

upon a table, and twisting, when the humerus 1ms suddenly given way 
:i little above the condyles.. This practice is called by the French 
"tourner poignet" the game of turning wrists. I have seen one case 
of this kind, which was under the rare of Dr. Winne, and Malgaigne 
has collected five other similar rases, two of winch were reported by 
Lonsdale. In L' Union Midicale is reported an example in which the 
fracture occurred on a level with the insertion of the deltoid, a little 
below the insertion of the pectoralis major and latissimus dorsi. The 
fracture seemed to be nearly transverse. 1 A case is also mentioned in 
the Canada Med. and Surg. Journ., 1875, the fracture occurring at 
about the same point. 

The example of fracture during birth, to which I have referred oc- 
curred in a healthy female child, whose parents were also healthy. 
The mother was in labor six or eight hours, but the labor was not severe. 
She was attended by a midwife, and does not know whether violence was 
employed or not. Dr. Lockwood, of Buffalo, was called on the third 
day. and found the arm broken a little below its middle, and moving as 
freely as it did at the elbow-joint ; he applied lateral splints with band- 
, etc. I saw the child with Dr. Lockwood on the seventeenth day 
after its birth. There was then a perfect ferrule of ensheathing callus 
surrounding the fragments, and which, oAving to the softness of the flesh, 
could be easily detected and defined. The fragments had been firm at 
least three or four days. Nearly a year after, I again examined the 
arm. and could not discover any traces of the accident. 

Dr. Lowerihardt has also reported a case in which the evidence was 
conclusive that the fracture was caused solely by the contractions of the 
uterus, which forced the arm against the pubes ; the arm being heard 
distinctly to sua}) when it was passing this point and while the hands of 
the accoucheur were not aiding in the delivery. In this case the humerus 
was broken in its upper third. 1 ' 

Dr. N. Fanning, of Catskill, N. Y., has reported to me the following 
as having occurred in his own practice: 

" Mrs. II., of Catskill, was delivered June 8, 1865, after a short and 
not severe labor, of a full-grown and healthy male child. The mother 
was well formed, with ample pelvis. The labor was natural, and the 
presentation the most favorable, the occiput corresponding to the left 
acetabulum : but immediately after the delivery of the head, a hand and 
a portion of* the forearm of the child were felt above the pubes. The 
Bhoulders and body were delivered very quickly after the head, and 
during a single pain. Just as the right shoulder of the child was pass- 
ing under the arch of the pubes, I heard a snap, not unlike that caused 
by the breaking of a pipe-stem, which I soon found, as I suspected, to be 
caused by the fracture of the right os humeri of the child in its upper 
third. - ' The bone united with some deformity. 

Dr. Fanning is of the opinion that, in this case, the contraction of 
the uterus, occurring while the arm of the child occupied some unusual 

1 Amer. Died. Times, vol. Lv. p. 158. 

2 Ldwenhardt, American Journal of the Medical Sciences, Januar}^ 1841, p. 250, 
from Medicin. Zeit., Mai 6, 1840. 



SHAFT BELOW THE SURGICAL NECK. 279 

position, was the cause of the fracture. It was certainly not due to any 
force applied by Dr. Fanning himself. 

Seat and Direction of the Fracture. — The seat of the fracture is more 
often below than above the middle of the bone: thus, 1 have found the 
fracture fourteen times near the middle, and the same number of times 
below the middle third, but only seven times above the middle third. 
The observations of Norris, who found four fractures of the shaft above 
the middle, and nine below, correspond with my own ; ! but M. Gueretin, in 
the same number of fractures, found nine above the middle and four below. 2 

The line of fracture is generally oblique, but more often transverse 
than in fractures of the clavicle, femur, or tibia. 

Displacement. — The direction of the displacement depends, no doubt, 
sometimes upon the precise point of the fracture and upon the action 
of the muscles operating upon the two fragments : thus, if the fracture 
takes place just above the insertion of the deltoid, the lower fragment is 
liable to be drawn upwards and outwards, in the direction of its fibres, 
while the upper fragment is carried toward the origin of the pectoralis 
major, etc.; but, in a great majority of cases, the influence, of these mus- 
cle- is more than counterbalanced by the direction of the force, and by 
the direction of the fracture. Practically, therefore, it is seldom of much 
importance to determine the exact point of fracture, as to whether it is 
just above or below the insertion of a particular muscle; nor, indeed, is 
it generally very easy to ascertain this point with much precision. 

The amount of displacement varies considerably in different persons 
and in fractures at different points, but it will average about three- 
quarters of an inch. When the fracture is produced by muscular action 
alone, it is generally transverse, and displacement seldom occurs. Such 
was the fact in every instance where my own patient broke the arm three 
times consecutively at different points ; and union was speedily accom- 
plished, and with no deformity. Dupuytren, however, saw a case which 
constituted an exception to this general rule. The fragments became 
completely separated, and were so movable that union could not lie 
effected, and he was compelled, after three months, to resorl to resection. 

The average shortening after these fractures, exclusive of those which 
do not shorten at all. seems to be about half an inch ; but a considerable 
number are never displaced, a- the fractures are so Dearly transverse 
that they are easily reduced and maintained in place, and consequently 
the total average of shortening is probably less than half an inch ; in a 
few cases \ f is much greater. Practically, tie- shortening is ;i matter of 
n i importance. In the case of Margaret O'Brian, admitted to my ward. 
Bellevue Hospital, April '.». L878, with ;i fracture of the humerus, near 
its middle, and treated with my splint, the fragments being united, the 
broken arm was found to be half an inch longer than the other. 

I have met with a number of examples of delayed and of fibrous union 
of this bote- after ;i fracture (exclusive of gunshol fractures). In the 
first example of a complete failure the fracture was in tie- lower third of 
the -haft, oblique and compound, and no union had taken place :it the 
end of five month-. The man \\;i- intemperate, but in pretty good 

1 Norris, A Journ. of Med. Sri.. January, 1842, vol. xix. \>. 28. 
M.' Licale, vol. i. p. 15. 



280 FRACTURES OF THE HUMERUS. 

health. 1 In the second case, the fracture had occurred a little below the 
middle of the bone, and it was simple. Five months after the accident 
this patient consulted me, when I found the elbow anchylosed, the fore- 
arm being fixed at a right angle with the arm.' 2 Neither of these patients 
had been under my care previously, but I learned that an intelligent 
Canadian surgeon had treated one of them, and the other had been seen 
and treated by several surgeons. 

In the third case, a lad, five years of age, received a fracture about 
three or four inches above the elbow-joint, by the passage across the 
limb of a heavy army wagon. The arm was dressed with splints, and in 
about live weeks several fragments of necrosed bone were removed by 
Dr. Pope, <»f St. Louis, and the splints were again applied. Ten months 
from the date of the injury, Dr. Brinton, of Philadelphia, operated by 
perforation, and reapplied splints. When the splints were removed, the 
limit was straight and apparently firm, but the bond of union gradually 
gave way, and when he came under my charge in November, 1864, more 
than two years after the accident, the arm was bent at an angle of 45°, 
and the union was fibrous only. Under my advice all restraint and 
dressings were removed, and he was sent into the country to improve his 
general health, with the understanding that I would operate at some 
future day. Subsequently, on the 14th of April, 1867, I resected the 
bone at the seat of fracture, securing the fragments w T ith wire, and sup- 
porting the arm with a gutta-percha splint. The result was a perfect 
bony union, and very useful arm. 

The fourth case is briefly as follows: Charles Cunz, get. about 35, 
broke his right arm a little below its middle, Oct. 29, 1876. He was 
placed under the care of an excellent physician, but, for some reason 
not satisfactorily explained, the fragments united only by fibrous tissue. 
March '2">, 1877, five months after the fracture had occurred, I incised 
to the hone, and with an ordinary steel gimlet transfixed the overlapping 
fragments. Splints were then applied. The gimlet was permitted to 
renin in six weeks, during which time it became quite loose, and an 
abscess formed below the wound. At the end of this time the bond of 
union was quite firm, hut the splints were continued six weeks longer. 
At this date the union remains perfect, the humerus is straight, and the 
usefulness of his arm is unimpaired. 

In a fifth ease, that of F. H. Fennell, of Pittston, Pa., set. 21, the 
right arm was broken below its middle, a simple fracture; pasteboard 
and wooden angular splints were employed, but only a fibrous union 
took place. When he consulted me, eight months after the accident, 
the fragments remained ununited, and overlapped one inch. He was 
Dot prepared to submit to the treatment 1 proposed, namely, perforation 
of the fragments, and I have not heard from him since. 

Muhlenberg, in hi- tables of delayed union and ununited fractures of 
long bones, including 656 cases, has recorded 21!> of the humerus: of 
13 treated by manual friction. 4 were c\ivv<\ and 9 failed; of 10 treated 
by mechanical appliances, 6 were cured, 3 relieved, and 1 failed; of 42 
treated by seton, \- were cured. '24 failed, and 1 died ; of 13 treated 
by immobilization, ~> woe cured, <> failed, and 1 died: of 88 treated by 

1 Report "u Deformities, etc., Case 33. 2 Ibid., Case 21. 



SHAFT BELOW THE SURGICAL NECK. 



281 



resection, 43 were cured, 31 failed. 6 were relieved, 2 died, and in 1 the 
result is unknown : of 35 treated by drilling, 21 were cured, 2 were 
relieved, and 11 failed. 

In a few cases the elbow has remained somewhat stiff a long time 
after the splints were removed : and in one case which was brought to 
my notice complete freedom of motion was not restored at the end of 
fifteen years. Generally, however, the motions of the elbow-joint have 
been very soon restored after the removal of the splints and sling. 

I ought to mention that, not unfrequently, fractures of the shaft of the 
humerus, and especially where they are occasioned by direct blows, are 
followed by great swelling, and sometimes by abscesses. In one instance, 
the fracture having taken place within the insertion of the deltoid muscle, 
the sharp extremity of the lower fragment was made to penetrate the flesh, 
causing an abscess, and finally tetanus, of which my patient soon died. 

Dr. Lee writes to me, under date of Oct. 13, 1876, that a simple frac- 
ture of the lower third of the shaft, occurring in a child six years old, 
terminated in gangrene, and demanded amputation. Two other similar 
cases have been reported to me. In all of these cases a question arose 
as to the causes of the gangrene; but the practice of the surgeons was 
sustained by the courts. 

Dec. 1, 1877, Peter Folan, set. 21, was admitted to Bellevue, with a 
fracture of the left humerus, near its middle. The fracture was caused by 
a fall from a wagon on the same day. My splint 
was applied, and it was continued four weeks, Fig. 75. 

when the fragment- were found united, hut lie 
was discovered to have paralysis of the extensor 
muscles of the left hand and fingers. Two or 
three months later, their condition had much im- 
proved. The arm was perfectly straight. The 
bandage was never tight, and the cause of the 
paralysis was unexplained. 

Muhlenberg, in his tables of united fractures, 
has recorded 219 of the humerus, in a total of 
656 of all of the long bones. 

Tie- following remarks of Malgaigne are too 
pertinent to be omitted in this connection : 
•• When there is great obliquity, with overlap- 
ping, or a fracture with splintering, or a multiple 
fracture, a certain amount of deformity is inevit- 
able, and th<- formation of callus demands one <>r 
two weeks more. With the inflammation comes 
also the danger of suppuration, and later, a rigidity 
of the articulations difficult to dissipate. In 
short, wo must not forget that of nil fractures, 
those of tho humerus are most liable to fail of 
consolidation." 

On tho other hand, we -hall find, in the case 
of this hone, as in ;<11 others, some remarkable 
exceptions, where, although tho fracture may ho compound, and badly 
comminuted, yet tho limb has been saved and made useful. 




extension ap- 
paratus. — A. Crutch. I'-. 
Shaft. C. Elbon reit. B. 
Hook for attachment of 
[oh i- 
;i crossbar (■><- tb< 



282 



K R ACT D R E s F T II K HUMERUS. 



Fig. 



Treatment — In the treatment of fractures of that portion of the shaft 
of the humerus now under consideration, we shall do best to adopt essen- 
tially the same plan which I have recommended for fractures of the 
Burgical neck. In proportion as the fracture occurs at a lower point of 
the humerus, however, will it he necessary to extend the long splint 
downwards, in the direction of the elbow ; so that, while in fractures of 
the surgical neck and upper half of the shaft it may not be necessary to 
extend the splint quite so low as the external condyle, in the case of 
fractures in the lower half of the shaft it will be necessary to include the 
condyles with the splints, and sometimes it may be necessary to employ 
the gutta-percha angular splint, which will be recommended hereafter in 
fracture- involving the elbow-joint. It is in these latter cases, also, that 
we shall find, sometimes, the plaster-of-Paris dressing, including the 
forearm, arm, and shoulder, giving the most satisfactory results : never 
neglecting, however, when using this or any other form of immovable 
dressing, to observe the condition of the arm frequently as to the swell- 
ing or shrinkage. Whenever the splints are made to touch or include the 
condyles, very great care must be taken to protect them from pressure. 

Other surgeons have sought to make permanent extension in these 
and certain other fractures of the humerus, by various contrivances. Mr. 
Lonsdale constructed an instrument which might be lengthened or short- 
ened to suit the case; it was made of steel, and was worked with a screw 

operating upon cogs in a sliding bar; 
resembling, in some respects, the arm 
portion of Jarvis's adjuster. In the 
second London edition of a series of 
plates illustrating the action of the mus- 
cles in producing displacement in frac- 
tures, by S. W. Hind, is a drawing of an 
apparatus invented by the author for the 
same purpose, which is very simple, and 
in some respects more complete than 
Lonsdale's, and which may be easily 
adapted to almost any form of arm- 
t^' f-^^^^ z --y^J -pi int. Indeed, nothing more is neces- 

sary than to attach to the ordinary long 
splint a movable crutch. 

Dr. Henry A. Martin, of Boston, has 
invented a splint, also for the purpose of 
making extension in fractures of the 
humerus, the counter-extension being 
made, by adhesive plasters, from the 
side of the chest. The apparatus is 
elongated by a ratchet operating upon 
two steel bars, which are thus made to 
move upon each other. 

In my opinion, and in the opinion of 
nearly all practical surgeons who have 
written upon this subject, it is impossible 
Clark's extension in fractures of the by these or any other similar contriv- 
neck of the humerus ances to make extension in fractures of 




SHAFT BELOW THE SURGICAL XECK. 283 

the humerus. The axilla can never be made a proper point of support 
for permanent counter-extension : and Dr. Martin's method, while it 
avoids the dangers of axillary pressure, cannot prove efficient. The ad- 
hesive plasters must inevitably fail to retain their places when even a 
moderate amount of traction is continuously made upon them. 

The late Dr. E. A. Clark, of the St. Louis City Hospital, proposed 
to accomplish the extension, in fractures of the head and surgical neck. 
by suspending a weight from the elbow. He reports one case success- 
fully treated by this method: and Dr. Tyndale, of New York, formerly 
his House Surgeon, informs me that several of the cases were treated in 
the same manner, all of them being in the lower third of the humerus. 
When the patient is in the recumbent posture, the weight must be sus- 
pended over a pulley. No doubt this is the only method by which really 
effective extension can ever be made in fractures of the humerus. There 
may be, perhaps, examples of fractures of the neck of the humerus in 
which the fragments overlap persistently, where it will be proper to 
resort to this novel expedient. When fractures occur above the deltoid, 
the overlapping is often excessive, and there is not much danger of their 
being forcibly separated by the extension : but in fractures below this. 
Dr. Clark's method might possibly expose to the danger of separation and 
non-union of the fragments, but it will be observed that this was the class 
of cases successfully treated by Dr. Clark. In the case of fractures of 
the neck, no splints are advised by Dr. Clark; yet. as a means of holding 
the lower fragment out. a single outside splint might he useful. 

I have seen a case of compound fracture of the humerus treated by 
Dr. Stephen Smith, at Bellevue, in this manner, while the patient was 
confined to the bed. with the most satisfactory results: and recently, in 
a case of fracture of the humerus, a little above the middle, complicated 
with other severe injuries, which eventually proved fatal, this method 
of extension was employed successfully by me. to prevent the violent 
spasmodic contractions of the muscles. In this case the arm and fore- 
arm were kept extended, the adhesive plaster extension strips being made 
fast to the hand and forearm, and the pulley and weight being arranged 
at the foot of the bed. 

In reference to those forms of apparatus which are intended t<> press 
upon the axillary margins, it ought to be stated here, since we have 
omitted to speak of it in connection with fractures of the Burgical neck, 
that in all fractures of the upper half or third of the humerus, including 
fractures of the surgical neck, they are not only useless, but they actually 
tend to defeat their own purpose. They are intended to replace the 
fragment- : but by their pressure upon the pectoralis major and latissimus 
dorsi, which compose the free margins of the axillary space, they must 
inevitably cause the separation of the fragments. 

Malgaigne, when speaking of the apparatus of Lonsdale, remark-: 
"But the surgeon should never lose sigh! of the facl thai permanenl 
extension i- ;> resource always dangerous, often useless, and which de- 
mand- in its application much caution and watchfulness. 

The following example will illustrate the practical difficulty of employ- 
ing permanent extension in fractures of the humerus: 

A laborer, aged thirty, was admitted into the Buffalo Hospital of the 



284 FRACTURES OV THE HUMERUS. 

Sisters of Charity, on the second day of October, 1853, with a simple 
oblique fracture of the humerus, which had occurred three days before. 
The fracture was situated within the insertion of the deltoid, and, having 
been produced by the rolling of a log upon the arm, the whole limb was 
much swollen. The night following his admission, in a fit of delirium 
tremens, he removed all of the dressings. When I visited the wards in 
the morning. I found the fragments displaced and the muscles contract- 
ing violently. The ordinary dressings were applied, and continued until 
the fifth day. when, as the delirium had not ceased, and the muscles 
continued to contract with great violence, it was determined to attempt 
permanent extension. For this purpose we lifted the elbow upwards and 
outwards, to relax the deltoid, and then, having made extension with the 
forearm placed at a right angle with the arm, we fitted carefully a large 
gutta-percha splint to the forearm, arm, axilla, and side, in such a man- 
ner that when the splint was secured to these several parts, the arm 
could not fall to the side of the body completely, and in proportion as it 
did fall downwards, it would make extension upon the arm. This splint 
was well padded, and secured in place by rollers. 

On the sixth day the delirium had ceased, and never returned. The 
dressings were well in place, and seemed to accomplish the indication 
we had in view : but, on the seventh day, although he had kept very 
(piiet. everything was disarranged, and the whole had to b6 readjusted. 
On the eighth and ninth the same thing occurred. During this time we 
had varied the dressings, position, etc., each day, to meet, if possible, 
the difficulties : but it was at length deemed unwise to pursue the attempt 
any farther, and we returned to the use of the ordinary splints, laying 
the arm against the side of the body. The union was finally completed 
without either overlapping or angular displacement. I have no doubt 
now that we would have done much better if we had resorted to exten- 
sion, as practised by Dr. Clark. 

Something may always be accomplished when the patient is walking 
about, by allowing the elbow to escape from the sling, so that its weight 
shall make constant traction upon the lower fragment; and the plan 
which I suggested some years since, of treating certain cases of delayed 
union of the humerus, namely, extending the arm at full length by the 
side of the body, so that the lower fragment shall receive the whole 
weight of the forearm and hand, might occasionally prove valuable in 
recent fracture- where the tendency to override was very great. 

The precise plan, and my reason for its adoption in certain cases of 
delayed union, were set forth in the following paper, read before the 
Buffalo City Medical Association, and published in the Buffalo Medical 
Journal for August, 1854. 

■•I have observed that non-union results more frequently after frac- 
tures of the -haft of the humerus, than after fractures of the shaft of any 
other bone. 

" Comparing the humerus with the femur, between which, above all 
others, the circumstances of form, situation, etc.. are most nearly paral- 
lel, and in both of which non-union is said to be relatively frequent, I 
find that of forty-nine fracture- of the humerus, four occurred through 
the surgical neck, twelve through the condyles, and twenty-nine through 



SHAFT BELOW THE SURGICAL NECK. 285 

the shaft. In one of the twenty-nine the patient survived the accident 
only a few days. In four of the remaining twenty-eight union had not 
occurred after the lapse of six months, and in many more it was delayed 
beyond the usual time. Two* of the four were simple fractures, and 
occurred near the middle of the humerus ; the third was compound, and 
occurred near the middle also ; the fourth was compound, and occurred 
near the condyles. 

"This analysis supplies us, therefore, with four cases of non-union, 
from a table of twenty-eight cases of fractures through the shaft. 

"Of eighty-seven fractures of the femur, twenty occurred through 
the neck, one through the trochanter major, and one through the con- 
dyles. The remaining sixty-five occurred through the shaft, and gener- 
ally near the middle, and not in one case was the union delayed beyond 
six months. 

" To make the comparison more complete, I must add that of the 
twenty-eight fractures of the shaft of the humerus, six were compound : 
and of the sixty-five fractures of the shaft of the femur, six were either 
compound, comminuted, or both compound and comminuted. The six 
compound fractures of the shaft of the humerus furnished two cases of 
non-union. The six cases of either compound or comminuted or com- 
pound and comminuted fractures of the femur, furnished no case of non- 
union. 

" I beg to suggest to the Society what seems to me to be the true ex- 
planation of these facte. 

•• It is the universal practice, so far as I know, in dressing fractures of 
the humerus, to place the forearm at a right angle with the arm. Within 
a few days, and generally, I think, within a few hours, after the arm and 
forearm are placed in this position, a rigidity of the muscles and other 
structures has ensued, and to such a degree that if the splints and sling 
are completely removed, the elbow will remain flexed and firm ; nor will 
it be easy to straighten it. A temporary false anchylosis has occurred, 
and instead of motion at the elbow-joint, when the forearm is attempted 
to be straightened upon the arm, there is only motion at the seat of frac- 
ture. It will thus happen that every upward and downward movement 
of the forearm will inflict motion upon the fracture; and inasmuch as 
the elbow has become the pivot, the motion ;it the upper end of the Lower 
Fragment will be the greater in proportion to the distance of the fracture 
from the elbow-joint. 

"No doubt it is intended that the dressings Bhall prevent nil motion of 
the forearm upon the arm: but I four thai they cannol always he made 
t i do this. I believe it is never done when the dressing is made without 
angular splints, nor is it by any means certain thai it will he accomplished 
when such splints are used. Tie- weight of the forearm is such, when 
placed at a right angle with the arm, and encumbered with splints and 
bandages, that even when supported by ;■ sling, i1 settles heavily for- 
wards, and compels tie- arm-dressings to loosen themselves from the arm 
in front of the point of fracture, and to indent themselves in the skin 
and flesh behind. By these means the upper end of the lower fragment 
18 tilted forward.-. U tie- forearm should continue to drag upon the 



286 FRACTURES OF THK HUMERUS. 

-lii i u:, nothing but a permanent forward displacement would probably 
result. The bones mighl unite, yet with a deformity. 

•■ Hi 1 1 the weighl of the forearm under these circumstances is not uni- 
form, nor do I Bee hofl it can be made ao/ It is to the sling that we must 
trust mainly to accomplish this important indication. But you have all 
noticed that the tension or relaxation of the sling depends upon the atti- 
tude of the body, whether standing or sitting; upon the erection or 
inclination of the head; upon the motions of the shoulders; and in no 
inconsiderable degree upon the actions of respiration. Nor does the 
patient himself cease to add to these conditions by lifting the forearm 
with his opposite hand whenever provoked to it by a sense of fatigue. 

*• This difficulty of maintaining quiet apposition of the fragments while 
the arm is in this position, at whatever point it may be broken, becomes 
more and more serious as Ave depart from the elbow-joint, and would be 
at it< maximum at the upper end of the humerus, were it not that here 
a mass of muscles, investing and adhering to the bone, in some measure 
obviates the difficulty. Its true maximum is, therefore, near the mid- 
dle, where there is less muscular investment, and where, on the one hand, 
the fracture is sufficiently remote from the pivot or fulcrum to have the 
motion of the upper end of the lower fragment multiplied through a long 
arm, while, on the other hand, it is sufficiently near the armpit and 
shoulder to prevent the upper portion of the splint and arm-dressings 
from obtaining a secure grasp upon the lower end of the upper fragment. 

•• It must not be overlooked that the motion of which we speak belongs 
exclusively to the lower fragment, and that it is always in the same plane 
forwards and backwards, but especially that it is not a motion upon the 
fracture as upon a pivot, but a motion of one fragment to and from its 
fellow. This circumstance I regard as important to a right appreciation 
of the difficulty. Motion alone, I am fully convinced, does not so often 
prevent union as surgeons have generally believed. It is exceedingly 
rare to Bee a case of non-union of the clavicle. Of forty-seven cases of 
fracture of the clavicle which have come under my observation, and in 
by far the greater proportion of which considerable overlapping and con- 
sequent deformity ensued, only one has resulted in non-union, and in this 
instance no treatment whatever w r as practised, but from the time of the 
accident the patient continued to labor in the fields, and hold the plough 
a- if nothing had occurred. I have, therefore, seen no case of non- 
union of the clavicle where a surgeon has treated the accident. Indeed, 
what is most pertinent and remarkable, its union is more speedy, usually, 
than that of any other bone in the body of the same size. Yet to pre- 
vent motion of the fragments in a case of fractured clavicle with com- 
plete separation and displacement, except where the fragment is near one 
of the extremities of the bone, I have always found wholly impracticable. 
Whatever bandage or apparatus has been applied, I have still seen always 
that the fragments would move freely upon each other at each act of in- 
spiration and expiration, and at almost every motion of the head, body, 
or upper extremities. It is probable, gentlemen, that you have made 
the same observation. 

" From this and many similar facts I have been led to suspect, for a 



SHAFT BELOW THE SURGICAL NECK. 287 

long time, that motion lias had less to do with non-union than was gen- 
erally believed. 

"I find, however, no difficulty in reconciling this suspicion with my 
doctrine in reference to the case in question : and it is precisely because. 
as I have already explained, the motion, in case of a fractured humerus, 
dressed in the usual manner, is peculiar. 

" In a fracture of the clavicle through its middle third (its usual situ- 
ation), the motion is upon the point of the fracture as upon a pivot; 
although, therefore, the motion is almost incessant, it does not essen- 
tially, if at all, disturb the adhesive process. The same is true in nearly 
all other fractures. The fragments move only upon themselves, and not 
to and from each other. I know of no complete exception but in the 
case now under consideration. 

** Aside from any speculation, the facts are easily verified by a per- 
sonal examination of the patients during the first or second week of 
treatment, or at any time before union has occurred, both in fractures of 
the humerus and clavicle. The latter is always sufficiently exposed to 
permit you to see what occurs ; and as soon as the swelling has a little 
subsided in the former case, you will have no difficulty in feeling the 
motion outside of the dressings, or, perhaps, in introducing the finger 
under the dressings sufficiently far to reach the point of fracture. I be- 
lieve you will not fail to recognize the difference in the motion between 
the two cases. Such, gentlemen, is the explanation which I wish to offer 
for the relative frequency of this very serious accident — non-union of 
the humerus. 

"I know of no other circumstance or condition in which this bone is 
peculiar, and which, therefore, might be invoked as an explanation. 
Overlapping of the bones, the cause assigned by some writers, is not 
sufficient, since it is not peculiar. The same occurs much oftener, and 
to a much greater extent, in fractures of the femur, and equally as often 
in fractures of the clavicle, yet in neither case are these results so fre- 
quent. Nor can it be due to the action of the deltoid muscle, or of any 
other particular muscles about the arm, whether the fracture be below or 
above their insertions, since similar muscles, with similar attachments, 
on the femur and on the clavicle, tending always powerfully to the sepa- 
ration of the fragments, occasion deformity, but they seldom proven i 
union. 

"If I am correct in my views, we shall be able sometimes to consum- 
mate union of a fractured humerus where it is delayed, by straightening 
the forearm upon the arm, and confining them to this position. A 
straight splint, extending from the top of the shoulder to the hand, con- 
structed from some firm material, and made fast with rollers, will secure 
the requisite immobility to the fracture. The weigh! of the forearm 
and hand will only tend to keep the fragments in place, and if the splint 
and bandages are sufficiently tight, the motion occasioned by swinging 
the hand and forearm will be conveyed almost entirely to the shoulder- 
joint. Aery little motion, indeed, can in this posture be communicated 
to the fragments, and what little is thus communicated is a motion, as 
experience has elsewhere shown, not disturbing or pernicious, but a 
motion only upon the end- of the fragments, as upon a pivot. 



288 FRACTURES OF THE HUMERUS. 

-•I do not tail to notice that this position has serious objections, and 
that it is Liable to inconveniences which must always, probably, prevent 
it^ being adopted as the usual plan of treatment for fractured arms. It 
la more inconvenient to get up ami lie down, or even to sit down, in this 
position of the arm, and the hand is liable to swell. But I shall not be 
surprised to learn that experience will prove these objections to have less 
weighl than Ave arc now disposed to give them. Remember, the prac- 
tice i- yet untried — if I except the case which I am about to relate, and 
in which case, 1 am free to say, these objections scarcely existed. The 
swelling of the hand was trivial, and only continued through the first 
fortnight, and the patient never spoke of the inconvenience of getting 
up or Bitting down, or even of lying down. 

'•The following is the case to which I have just referred: 'Michael 
Mahar, Laborer, set. 35, broke his left humerus just below its middle, 
Dec. 14, 185-3. The arm was dressed by a surgeon in Canada West, 
and who is well known to me as exceedingly " clever." After a few- 
day- from the time of the accident, "the starch bandage was put on as 
tight as it could be borne, and brought down on the forearm, so as to 
confine the motions of the elbow-joint." Six weeks after the injury, 
January '2 l .K 1854, Mahar applied to me at the hospital. No union had 
occurred. The motion between the fragments was very free, so that 
they passed each other with an audible click. There was little or no 
swelling or soreness. In short, everything indicated that union was 
not likely to occur without operative interference. The elbow was com- 
pletely anchylosed. I explained to my students what seemed to me to 
be the cause of the delayed union, and declared to them that I did not 
intend to attempt to establish adhesive action until I had straightened 
the arm. They had just witnessed the failure of a precisely similar case, 
in which I had made the attempt to bring about union without pre- 
viously straightening the arm. 

"'On the 6th of February, 1854, we had succeeded in making the 
arm nearly straight. I now punctured the upper end of the lower frag- 
ment with a small steel instrument, and, as well as I was able, thrust it 
between the fragments. Assisted by Dr. Boardman, I then applied a 
gutta-percha splint from the top of the shoulder to the fingers, moulding 
it carefully to the whole of the back and sides of the limb, and securing 
it firmly with a paste roller. March 4th (not quite four weeks after the 
application of the splint) we opened the dressings for the second time, 
and carefully renewed them. A slight motion was yet perceptible be- 
tween the fragments. March 18th, we opened the dressings for the 
third time, and found the union complete. This was within less than 
forty days. The patient was now dismissed. On the 29th of April 
following, the bone was refractured. Mahar had been assisting to load 
the ••tender to a locomotive. As the train was just getting in motion, 
lie was hanging to the tender by his sound arm, while another laborer 
Beized upon his broken arm to keep himself upon the car, and with a 
violent and sudden pull wrenched him from the tender and reproduced 
the fracture. The next morning I applied the dressings as before, and 
did not remove them during three weeks: at the end of which time the 



BASE OF THE CONDYLES. 289 

union was again complete. The splint was. however, reapplied, and lias 
been continued to this time — a period of about six weeks. 1 " ! 

Since the date of the above paper I have several times had oppor- 
tunities to test the value of this mode of treatment in cases of delayed 
union of the humerus, and in each case with the same favorable result. 
Donald Maclean, of Ann Arbor. Michigan, and several other surgeons, 
have adopted the same procedure in similar cases successfully. 2 

Measurement. — It may be well to indicate in this place by what 
method we shall best insure an accurate measurement of the arm, or 
forearm. 

In either case, the point from which the measurement can be most 
satisfactorily made above, is the posterior and inferior edge of the 
acromion process, at the most salient point of this margin, about oppo- 
site the scapuloclavicular articulation. If the arm can be straightened, 
the extremity of either of the fingers can be used as the lower fixed 
point. If the arm cannot be straightened, we may use as the lower 
point either condyle, or the point of the elbow. In order to get the 
point of the elbow accurately, the hands should be clasped in front 
of the body: and as the elbows are pressed back, a rule may be laid 
beneath, and the measurements made from the upper surface of the rule. 

$ 6. Base of the Condyles. 

Syn. — Supracondyloid Fractures of the Humerus. — Afalgaigne. 

Causes. — Of 18 fractures at this point. 12 occurred in children under 
ten years of age. the youngest being two years old. 

In 11 cases the fracture had been produced by a fill, and it is pre- 
sumed that the blow was received upon the elbow: in the remaining six 
3 the cause is not stated. I believe, therefore, that .this fracture La 

Fig. 77. 




Fracture at the base of the condyles. (From G 

irally the result of an indirect blow, inflicted upon tli<> extremity of 
the elbow ; in a few examples it has been produced by a blow received 
directly upon the point of fracture, ;i- by the kick of a horse, etc., bul I 

1 Buffalo Med. Journ., vol. x. pp. 1 1-1 17. 
- Maclean, Phys. & Slug., May. 1880; also -Inly. Ifi 
19 



290 



FRACTL'RES OF THE HUMERUS. 



have never, save in a single instance, been able to trace it to a fall upon 
the hand. Dr. Shearer, U. S. A., has reported a case also, which seems 
to have occurred in the same manner. 1 

Direction of the Fracture, Displacement, and Symptoms. — I think 
this tract urc is generally oblique, and its line of direction upwards and 
backwards ; in nine of the eleven cases where this point was determined, 
such has been its apparent direction, and the lower fragment has been 
found drawn up behind the upper. Once I have found the lower frag- 
ment in front, and once on the outside of the upper. 

Three of the 18 were compound comminuted fractures, this being a 
larger proportion of serious complications than is usually found in con- 
nection with fractures of long bones. 

Separation of the Loiver Epiphysis. — I have never met with what I 
supposed to be a separation of the lower epiphysis ; but surgical writers 






Fig. 79. 



Fig. 80. 




Lower epiphysis. 



Dr. JReeve's case of 
separation of the lower 
epiphysis. 



Dr. Lange's case of separation of lower epi- 
physis, and detachment of epicondyles. 



have occasionally spoken of this accident, and the late Dr. Watson, of 
>o-\\ York, believed that lie had seen one example in an infant not quite 
two years old. The limb had been violently wrenched by the mother, in 
attempting to lift her. She was not seen by Dr. Watson until the fourth 
day. at which time the swelling was such that the diagnosis could not be 
easily made out; but on the ninth day "it was apparent that the shaft 
of the humerus had been separated from its cartilaginous expansion at 
the condyles, near the elbow." By the use of angular pasteboard splints 



1 M. M. Shearer, Act. Asst. Burgeon, U. S. A. Boston Journ. of Chemistry, Feb. 



BASE OF THE CONDYLES. 291 

the reduction was maintained, and the fragments became united after 
about four or six weeks. 1 

Dr. J. C. Reeve, of Dayton. Ohio, lias sent me a specimen of epiphy- 
seal separation, which occurred in his practice in the year 1864. A girl, 
aet. 10, fell a few feet, striking, probably, upon her elbow. The frac- 
ture was compound, and union not haVing occurred at the end of three 
weeks, the condition of the arm rendered amputation necessary. In this 
case a small fragment of the shaft came away with the epiphysis. Drs. 
Little, Voss, Buck, 2 and Lange, 3 of this city, have each reported a simi- 
lar case. Champion, 4 so long ago as 1818, described the case of a hoy 13 
years old. in whom the epiphysis was torn on by the arm being caught 
in machinery: amputation became necessary, and the boy got well. Mr. 
Hutchinson 5 describes one case also. 

In Champion's case, and in Dr. Reeve's, amputation became neces- 
sary. In Hutchinson's patient the upper fragment projected and was 
excised : the patient recovering with a stiff elbow. In Dr. Lange's 
patient the epiphysis was removed through the wound, and a portion of 
the shaft excised. He recovered with a useful arm. 

I wish to call attention to the frequency with which examples of epi- 
physeal separation in the case of this bone, and of other bones, have been 
followed by suppuration. This will be found to be especially the met in 
separations of the trochanter major, of the lower end of the femur, and 
lower end of the tibia. I shall not attempt at present to offer an explana- 
tion. 

True Fractures at the Base of the Condyles. — The diagnosis of a frac- 
ture at the base of the condyles is attended with peculiar difficulties, and 
it has occasionally been mistaken for a dislocation of the radius and ulna 
backwards. Dupuytren says : u There is nothing so common as to see 
a fracture of the lower end of the humerus, immediately above the elbow- 
joint, mistaken for a dislocation backward :" and he mentions three cases 
which have come under his own observation. I have found an opposite 
error, however, by far the most frequent, namely, a dislocation of both 
bones backwards has been supposed to be a fracture. 

The sources of this embarrassment are found in the proximity of the 
fracture to the joint, in the rapidity with which swelling occurs, and in the 
striking similarity of the symptoms which characterize the two accidents. 

It will be necessary, therefore, to establish with care the differentia] 

diagnosis. The following are the signs of fracture: 

1. Preternatural mobility, which, owing to the rapidity of the swell- 
ing and the contraction of the muscles whose tendons are stretched over 
the projecting ends of the hours, is often bood lost, being succeeded, 
sometimes after ;■ few hours, by ;i rigidity equal to that which i< usually 
present in dislocations, or even greater. It is especially difficult t<» flex 
the arm, owing to the projection of the upper fragment into the bend of 
the elbow. 

1 Watson. New York Journ Med., Nov. L858, p i::<». Becond Beries, vol xi. 

* Little. V'--. and Bi rk Journ. Med., Nov. 1865, \>. 1 88. 
3 Lange, X. Y. Surg. 5 

* Champion, Journ. Comp. du dee Sri. Med., t. 1. 1818, p. 828; Gurlt, op. ''it., 

t. 1. 82. 

5 Hutchinson, Med. Times and Ga/.., 1866, 1. | , 



292 FRACTURES OF THE HUMERUS. 

'2. Crepitus. This can usually be detected at any period if the arm 
is sufficiently extended, so as to bring the broken surfaces again into 
apposition. 

8. When the extension is sufficient, reduction is easily effected, and 
the natural length of the arm is restored; but the limb immediately 
shortens when the extension is discontinued — especially if at the same 
moment the elbow is bent. This is a very important means of diag- 
nosis 

4. A careful measurement, made from the point of the internal con- 
dyle to the acromion process, declares a positive shortening of the 
humerus. 

."). By flexing and extending the forearm upon "the arm, while the 
fingers are placed upon the lower portion of the humerus, the projecting 
fragments can be felt. Generally, the upper fragment being in front of 
the lower, and pressing down into the bend of the elbow, its end cannot 
be so easily recognized; but the upper end of the lower fragment can 
easily be made out. posteriorly, when the forearm is considerably flexed. 
The lower end of the upper fragment feels more rough, and is less wide, 
than in dislocations. 

»j. The whole of the lower fragment is carried backwards, and with 
it the radius and ulna, producing a striking prominence of the elbow 
and olecranon process. Efforts to straighten the forearm upon the arm, 
when no extension is used, increase rather than diminish this pro- 
jection. 

7 . The forearm is slightly flexed upon the arm, the angle made at the 
elbow being 25 or 30 degrees. 

8. The hand and forearm are pronated. 

9. The relations of the olecranon process with the two condyles re- 
main unchanged. 

In a case of ejriphyseal separation, the lower end of the upper frag- 
ment lias greater breadth than in the case of a fracture at the base of 
the condyle, and the line of separation is nearer the end of the bone. 

Signs of a Dislocation of the Radius and Ulna Backiuards.—l. 
Preternatural immobility. That is to say, extension and flexion are 
limited, but there is almost always present a preternatural lateral mo- 
bility. 

•1. Absence of crepitus. It is in this joint especially that surgeons 
have been deceived by the chafing of the dislocated bones upon the in- 
flamed joint surfaces, and have supposed that they discovered crepitus 
when no fracture existed. The rapidity with which inflammation de- 
delops itself after dislocations of the elbow-joint, and the consequent 
abundant effusion of* lymph, afford the probable explanation of this fre- 
quent error. 

3. When reduced, the bones are not generally disposed to become 
again displaced, even though the elbow should be flexed. 

4. The humerus is not shortened, but the olecranon process approaches 
the acromion process. 

5. There are no sharp projecting points of bone. The lower end of 
the humerus may not always be felt in the bend of the elbow; but when 
it i< h-lt. it i- found to be relatively smooth, broad and round. 



BASE OF THE CONDYLES. 293 

6. A remarkable prominence of the elbow and olecranon process, 

which prominence is sensibly diminished when an effort is made to 
straighten the forearm on the arm. 

7. Forearm flexed upon the arm to about the same degree as in frac- 
ture. 

8. Hand and forearm pronated as in fracture. 

9. Relations of the olecranon process to the condyles changed very 
greatly. 

The most constant diagnostic signs are. then, in the case of a fracture, 
crepitus, shortening of the humerus, projection of the sharp ends of the 
fragments, and an increase of the projection of the elbow when an at- 
tempt is made to straighten the arm: and in the case of a dislocation, 
the absence of crepitus, humerus not shortened, while the olecranon ap- 
proaches the acromion process: the smooth, round head of the humerus 
lost, or indistinctly felt in the bend of the elbow, and the projection of 
the point of the elbow diminished when the attempt is made to straighten 
the forearm on the arm. 

It is proper, also, to repeat here what we have already said in rela- 
tion to the causes of this fracture. A fracture at this point is produced 
almost always by a fill upon the elbow, but a dislocation of the radius 
and ulna backwards can never be. On the other hand, a dislocation is 
produced, in most ases, by a fall upon the palm of the hand, while I 
have never known but one fracture above the condyles to be thus pro- 
duced. 

Results. — Xine times have I found the arm shortened from half an 
inch to one inch, or a little more. 

Muscular anchylosis is almost always present when the apparatus is 
first removed, and it is seldom completely dissipated until after several 
months: but I have found more or less anchylosis at seven and nine 
months: and twice after the lapse of three years the motions of the joint 
have been very limited. A few years since. I examined the arm of a 
gentleman who was then twenty-seven years old, and who informed me 
that when he was four years old he broke the humerus just above the 
condyles. There -till remained a sensible deformity at the point of 
fracture — he could not completely supine the forearm. The whole arm 
was weak, and the ulnar nerve remarkably sensitive. The ulnar side 
of the forearm, and also the ring and little fingers, were numb, and have 
been in this condition ever since the accident. I know the surgeon very 
well who had charge of this case, and I have no doubt that the treatment 
was carefully and skilfully applied. 

In June of 1850, I operated upon a lad. nine years old. by -awing 
off the pr _ :,d of the upper fragment, whose arm had been 

broken nine month- before. This fragment was lying in fronl of the 
lower, and the skin covering it- sharp point was very thin and tender. 
There was no anchylosis at the elbow-joint, bin the hand was flexed 
forcibly upon the wrist, the first phalanges of all the fingers extended. 
and the second and third flexed. Supination and pronation of the fore- 
arm were lost. The forearm aid hand were ;dm<>~r completely para- 
lyzed, but very painful at time-. The ulnar nerve could be felt : 
across the end of the 



294 FRACTURES OF THE HUMERUS. 

In the hope thai some favorable change might result to the hand by 
relieving the pressure upon the nerve, yet with not much expectation of 
success, I exposed the bone and removed the projecting fragment. The 
nerve had to be lifted and laid aside. About one year from this time I 
found the arm in the same condition as before the operation. 

Non-union is a result not so frequent in fractures at this point as higher 
up : but Stephen Smith, of the Bellevue Hospital, New York, reports a 
case of non-union in a young man of twenty-three years. He was ad- 
mitted to the hospital on the seventh day after the accident. The frac- 
ture was simple and transverse, yet at the end of four months he was dis- 
missed "with perfectly free motion at the point of fracture." 1 The 
failure to unite was attributed to a syphilitic taint. 

A case was tried a few years since in the Supreme Court at Brooklyn, 
N. Y., in which, after a simple fracture at this point, the arm being 
dressed with splints and bandages, the little finger sloughed off in a con- 
dition of dry gangrene, and the adjacent parts of the hand were attacked 
with moist gangrene. Drs. Parker and Prince believed that this serious 
accident was the result of bandages applied too tightly and suffered to 
remain too long, while Drs. Valentine Mott, Rogers, Wood, Ayres, Dixon, 
and others, believed the gangrene might have been due to other causes 
over which the surgeon had no control. 2 

A few years ago, a similar case occurred in the town of Spencer, Tioga 
Co., N. Y. ; a boy, six years old, having broken his humerus just above 
the condyles. The fracture was oblique. The surgeon who was called 
to treat the case was an old and highly respectable practitioner. I am 
not informed of the plan of treatment any farther than that a roller was 
applied. On the eighth day, a second surgeon was employed, who, finding 
the hand cold and insensible, removed all of the dressings ; after which 
the thumb and forefinger sloughed, with other portions of the skin and 
flesh of the hand and arm. The surgeon who was first in attendance 
was prosecuted, and the case was tried in the Supreme Court of that 
county, but the jury found no cause of action. Dr. Hawley, of Ithaca, 
and the late Dr. Webster, of Geneva Medical College, testified that, in 
their opinion, the death of the fingers was owing to the pressure of the 
fragment upon the brachial artery, and not to the tightness of the band- 



Dr. Gross has also informed us of still another case of the same char- 
acter, which occurred in Warren Co., Ky. A boy, ten years old, had 
broken his arm above the condyles, and his parents having employed a 
surgeon residing at some distance, the dressings were applied, and direc- 
ti<»]|v given to send for the surgeon whenever it became necessary. The 
parents saw the arm swell excessively, and knew that the boy was suffer- 
ing very much, but did not notify the surgeon until the tenth day, when 
the hand was found to be in a condition of mortification, and at length 
amputation became necessary. 

Long afterward, in the year 1851, when the boy became of age, he 
prosecuted his surgeon, but with no result to either party beyond the 
payment of their respective costs. 

1 Smith, New York Journal of Medicine, May, 1857, p. 386, third series, vol. ii. 

2 New 5Tork Medical Gazette, vol. xii. pp. 46,80, 111. 



BASE OF THE CONDYLES. 295 

A similar case has been reported to me by Dr. Lyman Twomley, of 
Little Valley, Cattaraugus County, in this State. Dr. Twoniley is a well- 
known and experienced surgeon and physician. In the fall of 1860, Dr. 
T. was called to a boy set. 7, who had fallen ten feet and broken his right 
arm at the base of the condyles. Although but twelve hours had elapsed, 
the limb was greatly swollen. The lower end of the upper fragment 
projected through the skin three inches. His pulse was feeble and in- 
termittent. Dr. T. administered chloroform and adjusted the fragments. 
Light splints were applied, and cold lotions. On the fifth day gangrene 
commenced, and on the seventh day Dr. T. amputated at the point of frac- 
ture. The wound resulted in the formation of a good stump. Examin- 
ing the limb after amputation, the joint was found filled with blood, in a 
putrid state, and the tissues above and below were infiltrated with the 
same. Both of the lateral and the anterior ligaments of the joint were 
badly torn. The biceps and brachialis anticus were much torn. A small 
portion of the olecranon process, and more of the coronoid processes were 
broken off. The brachial artery was ruptured, and the median nerve 
seriously injured. There was also a partial fracture of the carpal ex- 
tremity of the radius. 

When this boy became of age he entered a suit against the doctor for 
malpractice, in having, he affirmed, made an unnecessary amputation of 
the arm. I am informed that the allegations were not sustained by the 
Court, and in this decision all surgeons must heartily concur. 

While I would not deny that in some of the preceding cases the slough- 
ing might have been solely due to the tightness of the bandages, against 
which cruel and mischievous practice we cannot too strongly protest, a 
knowledge of the anatomy of these parts, and the opinions of the very 
distinguished gentlemen who testified in defence of these surgeons, must 
compel as to admit the possibility of such accidents where the treatment 
has been skilful and faultless. 

Treatment. — The splints formerly much employed in this country, in 
fractures about the elbow-joint, and perhaps still used by some American 
surgeons, are simple angular side-splints, without joints, such as those 
.mended by Physick; 1 angular pasteboard splints, felt, leather, 
gutta percha. etc.. or angular splints with a hinge, such as Kirkbride's, 2 
Thomas Hewson's, Day's. Rose's, Welch's, or Bond's. 

Kirkbride's splint, which is said to have been used in the Pennsylvania 
Hospital in several Instances, is composed of two pieces of board, con- 
ed together by a circular joint, and having eyes on the inner edge, 
two inches apart, and hole- through tin- splint at graduated distances be- 
tween them. There is also a swivel eye. passing through the upper pair 
of the splint, and riveted below. A wire is fastened to the swivel, and 
bent at right angles at its other extremity, of n size to fit the eyes and 
hob- in the splint. This splint, properly supported by pads, is to be 
placed either upon the outside or inside of the arm, and secured by 
roller-. When the angle is t<» be changed, the wire i- unhooked and 
removed to another eye, or t<- -.mo of tie- intermediate holes upon the 

1 Elements "f Sur<_ r "ry. by J - D raey, Philadelphia <-<lition. vol. i. p. ] ).",. 

2 American Journal of tie- M Lical £ p. 815. 



296 



FRACTURES OF THE HUMERUS. 



Bide of the splint. Dr. Kirkbride reports two cases of fracture of the 
lower part of the humerus treated by this plan, one of which resulted 
in anchylosis, but the other was much more successful. 



Pig. 81. 



Fig. 82. 




Welch's splint. The binges may be transferred 
to splints of different sizes. 

H. Bond, of Philadelphia, has contrived a very ingenious splint for 
the elbow-joint, and which is designed also to afford a complete support 
to the forearm. 

Fig. 83. 




Bond's elbow splint 

For myself, 1 generally prefer a thick sheet of gutta percha, moulded 
and applied accurately to the limb. It should be extended beyond the 
elbow to the wrist, so as to support the whole length of the arm, elbow, 
and forearm. Some experience in the use of wooden angular splints has 



EASE OF THE CONDYLES. 



297 



convinced me that they cannot be very Avell fitted to the many inequali- 
ties of the limb; and neither pasteboard nor binder's hoard has sufficient 
firmness, especially in that portion which covers the joint. Angular 
splints, furnished with a movable joint, possess the advantage of enabling 
us to change the angle of the limb at pleasure, and of keeping up some 
degree of motion in the articulation without disturbing the fracture or 
removing the dressings: but the 
crossbars of Day's and Rose's 
splints render them complicated, 
and are in the way of a nice ap- 
plication of the rollers ; while they 
are all equally liable to the objec- 
tion stated against angular wooden 
splints without joints, viz.. that 
they seldom can be made to fit 
accurately the many irregularities 
of the arm, elbow, and forearm. 
In applying the author's splint, 
care must be taken that the hu- 
meral portion is not too short, or 
the result will be an unnecessary 
degree of overlapping of the frag- 
ments. This may generally be 
avoided if the surgeon will first 
shape his material to the sound 
arm. while the whole length is 
underlaid with three or four thick- 
3 of woollen cloth. Welch's 
splints, made of a material pos- 
ttg ;i slight amount of flexi- 
bility, approach more nearly the accomplishment of all the indications 
than any other manufactured splint with which I am acquainted, but the 
number of cases in practice to which they are applicable will be found 
to be limited, while gutta percha has no limit in its application. 

Whatever material is employed, the splint should be first lined with 
one thickness of woollen cloth, or sonic proper substitute. A pretty 
large pledget of fine cotton batting ought also to be laid in front of 
the elbow-joint, to prevent the roller from excoriating the delicate and 
inflamed skin; and great care should be taken to protect the bony emi- 
nences about the joint, or, rather, to relieve them from pressure, by 
increasing the thickness of the pads above and below these eminences. 

A- a very early day, 80 early, indeed. a> the seventh or eighth day, 
the splint should be removed, and. while the fragments are steadied, the 
joint should be subjected to gentle, passive motion. This practice should 
be repeated ;i- often n- every -eer.n.l or third day. in order to prevent, as 
far as possible, anchylosis. If much swelling follows the injury, il is 
my custom to open the dressings, witlM»nr removing the splints, on the 
d or third day after the accident, or at any time when the symp- 
toms admonish of its necessity. Occasionally, il is well to change the 
angle of the splint before reapplying it. If the angular splint with a 




The author's gutta-percha ,<i»lint. 



298 FRACTURES OF THE HUMERUS. 

movable joinl is used, Blight changes may be made while the splint is on 
the arm ; bul if the angle is much changed without removing the rollers, 
they become unequally tightened over the arm. and may do mischief. 

When anchylosis lias actually taken place, we may more or less over- 
come the contraction of the muscles and of the ligaments by gentle, 
passive motion, or by directing the patient to swing a dumb-bell or some 
oilier heavy weight, as first recommended by Hildanus ; but we must 
hear in mind the danger of causing a refracture by Jtoo early or immode- 
rate force. 

§ 7. Fracture at the Base of the Condyles, complicated with Fracture 
between the Condyles, extending into the joint. 

This fracture, which is but a variety or complication of the preceding, 
is even more difficult of diagnosis; and its signs, results, and proper 
treatment differ sufficiently to demand a separate 
Jfio. 85. consideration. 

I have recognized the accident six times. 
Confined to no period of life, it seems to be the 
result of a severe blow r inflicted directly upon the 
lower and back part of the humerus, or upon the 
olecranon process. Dr. Parker, of New York, 
was inclined to regard an obscure accident about 
tiie elbow-joint, which he saw in a lad sixteen 
years old, as a longitudinal fracture of the hume- 
rus, with separation of one condyle, but which 
had been occasioned by a fall upon the hand. 1 
For myself, I should regard this latter circum- 
Fracture at the base of, and stance as presumptive evidence that it w r as not a 
between, the condyles. fracture of this character, yet I do not mean to 
deny the possibility of its occurrence in this way. 
Its characteristic symptoms are, increased breadth of the lower end 
of the humerus, occasioned by a separation of the condyles; displace- 
ment upwards and backwards of the radius and ulna; shortening of the 
humerus ; crepitus and mobility at the base of the condyles, with crepitus 
also between the condyles, developed by pressing them together; or in 
case the radius and ulna are drawn up and back, the crepitus maybe 
detected, after restoring these bones to place, by pressing upon the 
Opposite condyles. 

It- consequences are, generally, great inflammation about the joint, 
] ten i i;m ei it deformity, and bony anchylosis. An opposite result must be 
regarded ;«> fortunate, and as an exception to the rule. 

Of the treatment, we can only say that it must be chiefly directed to 
the prevention and reduction of inflammation; at least during the first 
few days. Nor is this inconsistent with an early reduction of the frag- 
ment-, and moderate efforts, by splints and bandages, such as I have 
directed in case of a simple fracture at the base of the condyles, to keep 
the fragments in place. No Burgeon would he justified in refusing alto- 

N w York Journal of Medicine, Nov. 1856, p. 391, 3d series, vol. i. 




FRACTURE AT THE BASE OF THE COXDYLES. 299 

gether to make suitable attempts to accomplish these important indica- 
tions ; but he must always regard them as secondary when compared 
with the importance of controlling the inflammation. 

When splints are employed, the same rules will be applicable, both as 
to their form and mode of application, as in cases of simple fracture 
above the condyles. Plaster of Paris, or some of the immovable forms 
of dressing, furnished with ample fenestra, will sometimes be preferred. 

The following examples will more completely illustrate the character, 
history, and proper treatment of these cases than any remarks or rules 
which I can at present make. 

A woman, set. 44, fell upon the sidewalk in January, 1850, striking 
upon her right elbow. I saw her a few minutes after the accident, bul 
the parts about the joint were already considerably swollen, and it was 
not without difficulty that the diagnosis was made out. The forearm 
was slightly Hexed upon the arm. and pronated. On seizing the elbow 
firmly, a distinct motion was perceived above the condyles, and a crepi- 
tus. I could also feel, indistinctly, the point of the upper fragment. 
"While moderate extension was made upon the arm, the condyles were 
pressed together, when it was apparent that they had been separated. 
On removing the extension, they again separated, and the olecranon drew 
up. She was in a condition of extreme exhaustion, and the bones were 
easily placed in position. 

An angular splint was secured to the limb, and every care used to 
support the fragments completely, but gently. 

From this date until the conclusion of the treatment the dressings 
were removed often, and the elbow moved as much as it was possible to 
move it. 

Seven months after the accident, the elbow was almost completely an- 
chylosed at a right angle. The fingers and wrist, also, were quite rigid. 
Six veins later, the anchylosis had nearly disappeared ; she could now 
flex and extend the ami almost as much as the other; the wrist-joint 
was free, and the fingers could be flexed, but not sufficiently to touch 
the palm of the hand. The line of fracture through the base could 1k> 
traced easily, but the humerus was not shortened. There was, more- 
over, much tenderness over the point of fracture through the base, and 
at other points. Occasionally, ;i slight grating was ooticed in the 
radio-humeral articulation. She experienced frequent pains in the arm, 
and especially along the back and radial border of the ring finger. 
During the first year or two after the accident, the arm wasted very 
much, but although the band remained weak, the muscles were now well 
developed. 

A gentleman was struck with the tongue of ;i carriage with which ;i 
couple of horses were running. The blow \\;i- received directly upon 
the back of the left elbow. Dr. Spragueand myself removed some small 
fragments of bone, and while opening the wound for this purpose, we 
could see distinctly tie- lino of fracture extending into the joint ae \\<'ll 
;i- across the bone. Tie- condyles were nol separated. 

Tin- subsequent treatment consisted only in the use of such means as 
would best support the limb, and mosl successfully combat inflammation. 
The ami and forearm were laid upon =i broad and well-cushioned angular 



300 FRACTUEES OF THE HUMERUS. 

splint, covered with oil cloth, to which they were fastened by a few light 
turns of a roller. 

Twelve years after, I found the humerus shortened one inch and a 
half. During the first year, he says, there was no motion in the elbow- 
joint, hut he ran now ilex and extend the forearm through about 45° ; 
when Qexed to a right angle, it seems to strike a solid body like bone. 
Rotation of the forearm is completely lost, the hand being in a position 
midway between supination and pronation. He suffers no pain, and his 
arm is quite strong and useful. No means have been employed to re- 
store the functions of the limb but passive motion at first, and subse- 
quently constant, active use of the hand and arm. 

The late Dr. Thomas Spencer, of Geneva, used to relate a case in 
which a surgeon was called to what he supposed to be a fracture of the 
lower end of the humerus, and which he treated accordingly, with splints, 
etc On the second or third day, another surgeon was called, who re- 
moved the s| dints and bandages, and pronounced it a dislocation of the 
radius and ulna backwards ; but he was unable to reduce it. 

After some time, the first surgeon was prosecuted for having treated 
a- a fracture what proved to be a dislocation. Dr. Spencer, who had 
examined the arm carefully, gave his testimony last, and at a time when, 
from the evidence, it seemed almost certain that the surgeon must be 
mulcted in heavy damages ; but he declared his belief that both surgeons 
were right, since, on measuring the breadth of the humerus through its 
two condyles, he found that the humerus of the injured arm was three- 
quarters of an inch wider than the opposite. His conclusion, therefore, 
was that the condyles had been split asunder and were now separated; 
that the first surgeon properly reduced this fracture, but that when, on 
the second or third day, the second surgeon removed the splints and the 
dressings, a contraction of the muscles had taken place and the disloca- 
tion occurred, the bones of the forearm being drawn up between the 
fragments. Dr. Spencer believed this was an example of the variety of 
fractures now under consideration, but it is not quite certain that there 
was anything more than an oblique fracture extending into the joint, fol- 
lowed by a dislocation. In either case, the first surgeon was entitled to 
an acquittal, and so the jury promptly declared by their verdict. 

Although the flexed position must usually be regarded as the best in 
these fractures, for the reason that it most completely relaxes the biceps, 
brachialis anticus, and the flexors of the forearm, and because if anchy- 
losia ensues the flexed position gives the most useful arm, yet I think it 
might he proper to try what better may be accomplished by permanent 
extension, with the forearm straightened upon the arm, according to the 
method Dr. Clark, described in the preceding pages. 

In a case of compound comminuted fracture of the character now under 
consideration, Dr. Stone, of the Bellevue Hospital, New York, removed 
the condyles and sawed off the sharp end of the humerus. The woman 
was twenty-six years old and intemperate. The operation was made as 
a substitute for amputation. Xo serious complications followed. On 
the ninety-sixth day the wounds were completely healed, and she could 
bend the forearm to a right angle with the arm, the action of the muscles 
having drawn up the radius and ulna against the lower end of the shaft 



FRACTURE AT THE BASE OF THE CONDYLES. 301 

of the humerus, so that the motions were natural and free. 1 The prac- 
tice, as the result sufficiently shows, was eminently judicious: and its 
practicability ought always to be well considered before resorting to the 
serious mutilation of amputation. The great principle upon which the 
success of resection is here based is the shortening of the bone, whereby 
the reduction may be accomplished without painful tension to the muscles ; 
a principle which will demand of us hereafter a more careful consid- 
eration and a wider application. 

Fractures and Diastases of the Condyles and Epicondyles, 

Chaussier described that portion of the lower end of the humerus 
which articulates with the ulna as the trochlea, and that portion which 
articulates with the radius as the condyle : naming the two lateral pro- 
jections, respectively, epitrochlea and epicondyle. Some of the French 
writers have adopted this nomenclature, but I prefer, as being more 
familiar to my own countrymen, the terms external and internal condyles, 
to which it will be convenient to add the terms external epicondyle and 
internal epicondyle. as indicating the abrupt lateral projections on either 
side of the condyles, of which the largest portions are epiphyseal. These 
crest- or projections are formed in part by a prolongation of the outer 
and inner elevated margins of the humerus, and in part from separate 
centres of ossification, which in early life mainly overlie the two sides 
of the lower epiphysis. In advancing years these lateral epiphyses 
prolong themselves upwards to reach and partially overlie the humeral 
portions: the outer epiphysis becomes united by bony tissue to the shaft 
or humeral apophysis, about the sixteenth or seventeenth year ; while 
the inner epiphysis much larger than the outer, is not united usually to 
[responding apophysis until the eighteenth year. Gurlt places Tin- 
period of union of both of these epiphyses a year or two later. 

I shall hereafter speak of the epicondyles as all of those portions of 
the lower end of the humerus which project abruptly from the condyle-, 
aid are composed in large part of the lateral epiphyses, but not entirely. 
Practically, this definition leave- no portion of the lower extremity of the 
humeru- outside of the capsule except the epicondyle-. I say "practi- 
cally, it leaves do portion outside except tbe epicondyles which 
could possibly be broken off by an external or traumatic injury. We 

shall therefore have to -peak only of fractures of the epicondyle-. and of 

if the condyles involving the joint; the condyle- proper, as 
distinguished from the epicondyles, constituting on the one hand the 
outer end of the lower extremity of the humerm, including so much of 
the articular surface as belong- to the eminentia capitata : and, on the 
other hand, so much of the inner portion of the articular Burfac 
include- the trochlea. 

A- the reader will -<•.• hereafter, th.- epicondylar separations consist of 
two varieties, one of which is an epiphyseal separation, and the other a 
true fracture : one of which include- only a portion of the epicondyle, 
and the other includes the whole. The remaining fractures will all be 
intracapsular. 

i Sjto: ." ' Journ. of ] 



302 FRACTURES OF THE HUMERUS. 



§ 8. Fracture of the Internal Epicondyle ; and Fracture or Diastasis 
of the Internal Epicondylar Epiphysis. 

I will here add, to what I have already said in the preceding pages of 
the anatomy and development of the humerus, the very careful descrip- 
tion of the development of the lower end of the humerus given by Dr. 
Zuckerkandl, Demonstrator of Anatomy in the University of Vienna. 1 

" The inferior extremity of the humerus proceeds from a synostosis of 
five separately developed portions of bone. These are: 1st, the humeral 
diaphysis, which includes the supratrochlear fossa, a minute portion of 
the eminentia capitata, and on the dorsal surface the ribbon-like zone of 
the trochlea ; 2d, the trochlea ; 3d, the eminentia capitata ; 4th and 5th, 
the epicondyles. On the fully formed humerus that part is called the 
internal epicondyle which projects lever-like above tbe trochlea, and 
serves as the point of origin of the flexor group. Though this bony 
prominence presents itself as a united whole at this stage, still an exami- 
nation of the humerus, in the earlier periods of its development, teaches 
us that the internal epicondyle of the adult consists of two pieces, the 
superior of which belongs to the humeral diaphysis, to the median sur- 
face of which the osseous nucleus of the epicondyle applies itself, 
enlarges, and finally unites with the upper portion to form the lever of 
the flexor group of muscles. Accordingly what, in ordinary acceptation, 
is called a fracture of the epicondyle is something more, since it includes 
also a part of the humerus. It is difficult to believe, that only that part 
of the internal epicondyle, which corresponds to the epiphyseal centre of 
ossification, should be broken off in the adult, so that distinct cases of 
epicondylar fracture can occur only in youthful persons. 

"What we call external epicondyle, on the completely developed 
humerus, and a small portion of which (called 'la petite saillie,' in the 
above quotation from Mai gaigne) can be felt and seen through the skin 
of the arm in lean subjects, belongs, as taught by embryological observa- 
tion, not properly to the external epicondyle, but represents the most 
inferior prominence of the crista externa humeri, with which the more 
posteriorly extending epiphyseal nucleus of the external epicondyle 
finally unites. The epicondyles of adults, therefore, belong partly to 
the humerus and partly to the actual epiphyseal epicondyles, as a glance 
al the humeri of young persons teaches us. From the real internal 
epicondyle. which we term epiphyseal, arise the radialis internus, ulnaris 
internus, palmaris longus, and a small portion of the pronator teres, while 
from that part of the epicondyle which belongs to the humeral diaphysis, 
arises the greater portion of the pronator above named. On the external 
epiphyseal epicondyle are found the common extensor of the fingers, the 
olnans externus, and the anconeus quartus." 

These views of the anatomy and development of the condyles and 
epicondyles, and which are no doubt correct, compel me to reconsider 

1 Zuckerkandl, un the Epicondylar Fracture of the Humerus. Hosp. Gazette, 
Sept. 27, L879. Separat-Abdruck aus der "Allgem. Wiener Mediz. Zeitung," 1878,. 
Nr. 9. 



FRACTURES OF THE INTERNAL EPICONDYLE. 303 

the statements I have made in the earlier editions of this work, and to 
correct certain errors into which the author, in common with all other 
writers, has fallen in the classification of certain reported examples of 
fractures of the epicondyles. Hitherto, while in speaking of fractures 
of the internal epicondyle, I have distinctly stated thai my remarks were 
limited to separations of the epieondylar epiphyses. I have not hesitated 
to include as proper examples those eases in which I believed the entire 
epieondylar projection to be included. Other writers have, without 
exception so far as I know, done the same. The observations of Zuck- 
erkandl, however, show that, as I have before stated, these extreme pro- 
jections are composed only in part of the true epieondylar epiphyses. 
We must then hereafter speak of those separations which are epieon- 
dylar. and only epiphyseal, as composing one class of accidents, and 
which must be in a great measure peculiar to children; and of those 
which are epieondylar, but include also that portion of the epicondyle 
which is not epiphyseal, as another class, belonging chiefly to adults, but 
possible in children. 

According to Znckerkandl, it has been observed by Rambaud and 
Renault that there is sometimes a persistence of the epiphysis, the sepa- 
ration continuing to adult life ; from which we must infer that an epi- 
eondylar epiphyseal diastasis might take place in the adult, but it must 
nevertheless be very infrequent. We can have, usually, no means of 
determining this point except in the autopsy, and we must therefore be left 
in doubt sometimes whether a particular clinical case is to be regarded 
as an epiphyseal separation or a true fracture: our only means of differ- 
ential diagnosis being the probabilities afforded by the age of the patient, 
the cause, and the size ami form of the fragment. 

In treating of this subject then we can only relieve ourselves of the 
embarrassment by treating of epieondylar fractures and diastases .1- a 
class, existing in two subordinate forms — namely, one in which only the 
epiphysis is torn off before bony union to the crista humeri has taken 
platt — a true diastasis; and the second, in which, bony union having 
l.een completed, the whole of the extreme projection or epicondyle is 
Beparated from the shaft — a true fracture. 

We shall consider first — 

Die. the Epiphyseal Portion of the Internal Epicondyle. 

This i- probably the accident which Granger first described, and which 
3 xibed solely to muscular action. He do<-^ uot speak of it. however, 
as a diastasis of the epicondyle, but as "a particular fracture of the in- 
ternal condyle." 

•A distinguishing circumstance attending this fracture," says Mi-. 
Granger, "is that of it- being occasioned by sudden and violent muscu- 
lar exertion : and it will be recollected that from the inner condyle those 
powerful muscles which constitute the bulk of the fleshy substance of the 
ulnar aspect of the forearm have their principal origin. The way in 
which the muscles of the inner condyle are involuntarily tin-own into 
such sudden and excessive action I take to be this: the endeavor to pre- 



304 FBACTURES OF THE HUMERUS. 

vent a fall by Btretching out the arm. and thus receiving the percussion 
from the weight of the body on the hand" 1 

It is a tact of significance in this connection, that most of these frac- 
tures hitherto reported as epicondylar have occurred in children, before 
the union of the epiphysis is completed, when muscular contraction 
might more often prove adequate to its separation, and when the epicon- 
dyle is less prominent, and, therefore, less exposed to direct blows than 
in adult life. M. A. Cesar has collected fourteen cases, of which num- 
ber only four were adults, two were from eight to ten years old, five 
from eleven to twelve, and three from fifteen to sixteen. 2 While of five 
fractures which I have regarded as fractures of the epicondyle, all except 
one occurred between the ages of two and fifteen years. But then it is 
equally true that a large majority of all the fractures of the internal 
condyle, including those which enter the articulation, as well as those 
which do not. belong to childhood and youth. I have seen but two ex- 
ceptions in fifteen cases. Since, then, direct blows generally produce 
those fractures which penetrate the joint, no good reason can be shown 
why they should not sometimes produce fractures of the epicondyle. 
One of the exceptions to which I have referred as not having occurred 
in early life, is sufficiently rare to entitle it to especial notice. 

On the 16th of May, 1856, a laborer, thirty -four years of age, fell 
from an awning upon the sidewalk, dislocating the radius and ulna 
backwards ; the dislocation was immediately reduced by a woman who 
came to his assistance, but when he called on me soon after, I found a 
small fragment of the inner condyle, probably the epicondyle alone, 
broken off and quite movable under the finger. It was slightly displaced 
in the direction of the hand. 

I could not learn positively whether in falling he struck the elbow or 
the hand, but there was presumptive evidence that he struck the hand ; 
if so, then probably the fracture was the result of muscular action, which 
is the more extraordinary as having taken place in a man of his age, but 
in which case it must be assumed that the epiphyseal union was delayed. 

It is pretty certain, however, that the theory of causation adopted by 
Granger is too exclusive. A lad was brought to me in October, 1848, 
aged eleven, who had just fallen upon his elbow, the blow having been 
received, as he affirmed, and as the ecchymosis showed pretty conclu- 
sively, directly upon the inner condyle. The fragment was quite loose, 
and crepitus was distinct. He could flex and extend the arm, and rotate 
the forearm, without pain or inconvenience. I am quite sure the frac- 
ture did not extend into the joint; the result seemed also to confirm this 
opinion', for in three months from the time of the accident the motions 
of the elbow-joint were almost completely restored. Out of fourteen 
cases collected by Cesar, at least eight, says Poinsot, were produced by 
a direct cause. 

Indeed. Mr. Granger has failed to establish, by any particular proofs, 
that in more than one or two of his cases the fracture was the result of 

1 " On a Particular Fracture of the Inner Condyle of the Humerus," by Benjamin 
a r. Surgeon, Burton-upbn-Trent. Edinburgh Med. and Surg. Journ., vol. xiv. 
].. !'.'•;. April.' 1818. 

. Essai aur la frac. de l'epitrochlee, th. de Paris, 1876. 



FRACTURES OF THE INTERNAL EPICONDYLE. 305 

muscular action ; but, on the contrary, I am disposed to infer, from the 
violent inflammation which generally ensued in his cases, from the fre- 
quency of ecchymosis, and especially from the injury done to the ulnar 
nerve in at least three instances, that most of them were produced by 
direct blows inflicted from below in the fall upon the ground. Fractures 
produced by muscular action are seldom accompanied with much inflam- 
mation or effusion of blood, and it is much more probable that the ulnar 
nerve should have been maimed by the direct blow which caused the 
fracture, than by the displacement of the epiphysis, which is, as I shall 
presently show, almost always carried downwards, and oftener slightly 
forwards than backwards. It is only when the fragment is forced directly 
backwards that the ulnar nerve could be made to suffer; a direction which, 
ir does not seem to me, it could ever take from muscular action alone. 

Of all the cases above alluded to, including Granger's cases, it may be 
justly said that they were not verified by an autopsy, and that they do 
not. therefore, prove absolutely the existence of such a diastasis. 

In a case reported by Denuce, there was an exostosis resulting from 
a fracture, which caused paralysis of the ulnar nerve; but there is no 
evidence that the injury to the nerve was the result of displacement of the 
fragment. It was cured, however, by excision of the exostosis. 1 

Poinsot suggests that when a fracture of the internal epicondyle is 
caused by a fall upon the hand, the result may sometimes be due rather 
to the action of the internal lateral ligament than to muscular action ; 
and he says lhat Granger, Fergusson, Dale, and Richet have observed 
- of this kind. He, however, refers to one case mentioned by Hirtz, 
in which the accident was declared to be plainly the result of muscular 
action, it being occasioned in a little boy by the act of raising himself by 
his arms while suspended from a trapeze. 

Malgaigne speaks of this accident as a "fracture of the epitrochlea;" 
evidently including in this term all of the epicond}dar projection. He 
states, however, that "there is good ground for supposing that, in some 
cases at least, it is a disjunction of the epiphysis." Gurlt distinctly 
states, also, that clinical experience shows that both the inner and outer 
epiphyses are sometimes broken, however difficult it may be to demon- 
strate the fact anatomically. The case of which he furnishes an illus- 
tration in his book (p. 707, Fig. 1 09), and as being in the pathological 
collection at Wiirzburg, may Indeed have been a fracture of the entire 
internal epicondyle, including both the epiphysis and the apophysis, but 
there is no evidence or pretence that it was the epiphysis alone. 

The specimen described by Zuckerkandl, found in the dissecting-room, 
and without a clinical history (Fig. 86), and which he has kindly senl 
to me. is probably the only example of which we can -peak with any 
degree of positiveness as having hem sustained by an autopsy. The 
following is his accounl of the specimen : 

"The separation of the internal epicondyle I found on the loft arm of 
a strong-boned man. After the removal of the flexors, the epicondyle 

1 Poinsot, op. cit., pp. 314-317. 

2 HandbucL der lehre von den Knochenbruchen. Von Dr. B. Gurlt, Prof, der 
Chirurgie an der Kdniglichen Univeraital zu Berlin. Hamm, 1862, pp. 796, 7^*7. 



306 



FRACTURES OF THE HUMERUS. 



appeared projecting forwards tumor-like, but immovable, so that at first 
sight I thought of a fracture healed by callus. As I removed the dense 
connective tissue, which surrounded the epicondyle, there appeared a 
furrow, which encircled the irregular bony prominence, and formed a 
sharp line of demarcation between it and the humeral epicondyle. The 
tumor-like bony prominence, therefore, represented the epiphyseal epi- 
condyle. On farther examination it was seen that the epiphyseal was 
connected with the humeral epicondyle only by dense tissue, was irregu- 
larly formed on its uneven upper surface, slightly concave on its superior 
attached side, and of about the size of an os lunatum. 

ki In the figure is plainly seen the intact humeral epicondyle, the epi- 
physeal epicondyle, and between them the above-described furrow, which 
was tilled with fibrous tissue. The separated epicondyle does not corre- 
spond in form to that of a youthful person, nor to the inferior part of the 
flexor condyle in the adult. Its long axis in the latter is parallel with 
that of the humerus — in our preparation, however, it is sagittal, twisted, 
as it were, on its axis. The inferior portion of the epicondyle is in the 
adult about one-half cm. distant from the edge of the trochlea, but it is 
more than one cm. removed in this preparation; so that the lateral 
surface of the trochlea is very deep. " 

The bone is from an adult, as stated by Dr. Zuckerkandl, but he has 
omitted to mention that the coronoid fossa is small, and the olecranon 
fossa is nearly obliterated, indicating that for a long time before death 
the motions of the joint were limited. The presumption is, therefore, 
that this was an old fracture; a fact which increases greatly the diffi- 
culty of determining precisely the original character of the accident. 

There is a broad vertical and remarkable facet mentioned by Dr. 
Zuckerkandl on the inner side of the trochlea; the outer condyle 

is probably not normal in its 
shape, and altogether there are 
indications that the bone has at 
some time suffered a very severe 
and perhaps complicated injury. 
Perhaps there was more than one 
line of fracture ; possibly a trans- 
verse fracture through the shaft 
at the base of the condyles, or 
through the line of the epiphyseal 
junction. If such were the fact, 
the specimen does not illustrate 
a simple fracture of the epicon- 
dyle ; but these are points which 
the ancient character of the frac- 
ture does not permit us to deter- 
mine positively. 

We think, however, this may 
properly be called a separation 
of the epiphyseal portion of the 
interna] epicondyle, but whether it was a simple fracture or separation, 
uncomplicated with any other lesion of the bone, cannot now be determined. 




Separation of the epiphyseal portion of the in- 
ternal epicondyle. (ZuckerkandPs specimen.) 



FRACTURES OF THE INTERNAL EPICONDYLE. 307 

Direction of Displacement. Symptoms, etc. — I have seen what I 
suppose to be this epiphysis displaced in the direction of the hand, or 
downwards, very manifestly, twice, and in two other examples a careful 
measurement showed a slight displacement in the same direction. The 
greatest displacement occurred in a boy fifteen years old, who was 
brought to me from St. Catharine, Canada West. He had fallen upon 
his arm in wrestling, and his surgeon found a dislocation of the bones of 
the elbow-joint, which he immediately reduced. The diastasis of the 
epicondyle was not at that time detected, the arm being greatly swollen. 
No splints were applied. It was three months after the accident when 
I saw him, at which time I found the internal epicondyle removed 
downwards toward the hand one inch and a quarter; and at this point 
it had become immovably fixed. Partial anchylosis existed at the elbow- 
joint, but pronation and supination were perfect. 

In one instance I believed the fragment to be carried about three 
lines upwards and two backwards toward the olecranon ; in each of the 
other examples the fragment did not seem to be displaced. 

Granger found, also, in the five examples which came under his 
notice, the epicondyle carried toward the hand, with more or less varia- 
tion in its lateral position, so that while in some instances it touched 
the olecranon, in others it was removed an inch or more in the opposite 
direction. 

It is probable that, except where controlled by the force and direction 
of the blow, of by some complications in the accident, the fragment, if 
displaced at all, always moves downwards toward the hand, or downwards 
and a little forwards, in the direction of the action of the principal 
muscles which arise from this epiphysis; and when the fracture or sepa- 
ration is the result of muscular action alone, this form of displacement 
seems to me to be inevitable. In addition to the small size, mobility, 
crepitus, and generally slight displacement of the fragment, which, in 
connection with the age of the patient, are the principal signs of this 
fracture, it may he noticed that there is usually some embarrassment in 
the motions of the elbow-joint, which may be due in part to the swelling, 
and in part to the detachment of the point of hone from and around 
which most of the pronators and flexors of the forearm have their rise. 
In one instance, already quoted, that of the lad aged eleven years, who 
i- supposed to have had a detachmenl of the epiphysis from a direct 
blow, the motion- of pronation, with flexion, were not ;) t all impaired, 
neither immediately, nor ;it any subsequent period, hut the fragment was 
never sensibly, or only rery -lightly, displaced. 

Granger has recorded another class of symptoms, to which I have 
already alluded, his explanation of which, however, I am not prepared 
to admit. One of these cases he describes a- follows: A hoy, eight. 

- old, fell with violence. ;ind broke off completely the whole of the 

inner epicondyle of the right humerus. The hid said he had fallen on 
hi- hand. The fragment was displaced toward the hand. Severe in- 
flammation followed, but he recovered the h<-<- and entire use of the 
elbow-joint in less than three months after the accident. No splints or 
bandage- were ever employed. 

Prom the moment of the accident, the little finger, the inner lide of 



308 FRACTl RES OF THE HUMERUS. 

the ring finger, and the skin on the ulnar side of the band, lost all sen- 
sation. The abductor minimi digiti and two contiguous muscles of the 
little finger were also paralyzed. This condition lasted eight or ten 
years, after which sensation and motion were gradually restored to 
these parts. As a consequence of this paralyzed condition of the ulnar 
nerve, also, successive crops of vesications, about the size of a split 
horse-bean, commenced to form on the little finger and ulnar edge of the 
hand sonic weeks after the accident, leaving troublesome excoriations. 
This eruption did not entirely cease for two or three months. 

In two other cases, Mr. Granger remarks that he found "the same 
paralysis of the small muscles of the little finger, the same loss of feeling 
in the integuments, and the same succession of crops of vesicles on the 
affected parts of the hand, as occurred in the preceding case." 

Without intending to intimate a doubt of the accuracy of Mr. Granger's 
statement, that such phenomena have followed in three cases out of the 
five which he has seen, I must express my belief that it was only a re- 
markable occurrence of circumstances, since the same phenomena have 
never been seen by myself, nor do I know that they have been observed 
by any other surgeon. That they indicated some injury to the ulnar 
nerve is no doubt correct, but it is not so plain that it was caused by the 
displacement of the fragment. 

Results. — As in all other accidents about the elbow-joint, a temporary 
rigidity is likely to ensue. The mere confinement of the arm in a flexed 
position is sufficient to determine this result without the interposition of 
a fracture ; but when inflammation occurs, more or less contraction of 
the tendons, muscles, etc., about the joint must ensue. To this circum- 
stance, therefore, added to the confinement, rather than to the fracture, 
will be due the anchylosis. If the fragment is not displaced, the frac- 
ture cannot certainly be responsible for the loss of motion, since it does 
not in any way involve the joint; and if displacement exists, its ulti- 
mate effect in diminishing the power of the muscles which arise from the 
epiphysis must be only trivial and scarcely appreciable. We might, 
therefore, reasonably conclude that where the accident has been prop- 
erly treated, permanent anchylosis would be the exception, and not the 
rule. This view of the matter seems also to be sustained by the recorded 
results. In Granger's cases, the full range of flexion and extension of 
the forearm has been finally restored, or with so trifling an exception as 
not to be observable without close attention, in every instance; except 
in the one already mentioned, which was originally complicated with dis- 
location; and even in this case the ultimate maiming was inconsiderable. 
Malgaigne, who says "it ought to be understood that in this accident 
articular rigidity is almost inevitable," seems nevertheless to admit the 
justness of Granger's observation as to the final result, if the proper 
means are employed to prevent it. I have myself found only once any 
considerable anchylosis of the joint after the lapse of a few years. 

Treatment. — This accident does not constitute an exception to the rule 
which experience has established, that small epiphyseal projections, when 
once displaced, can seldom be restored completely to, or maintained in 
position. Granger remarks: k * I have purposely avoided saying one 
word about replacing the detached condyle" (epicondyle), "and for 



FRACTURES OF THE EXTERNAL EPICONDYLE. 309 

these reasons : during the state of tumefaction of the limb, no means 
could be adopted for confining the retracted condyle in its place, beyond 
that of the relaxation of the muscles: and both before the tumefaction 
has commenced, and after it lias subsided, all endeavors to replace the 
condyle, or even to change the position of it. have failed." lie even pro- 
ceeds so far as to declare that, while attention ought to he given to the 
reduction of the inflammation by appropriate means, we ought, never- 
theless, to instruct the patient to flex and extend the arm daily from the 
moment the accident occurs until the cure is completed, and without any 
regard to the consolidation of the fragment : " the exercise of the joint 
in this manner must constitute the principal occupation of the patient for 
several weeks : and should it be remitted during the formation and con- 
solidation of the callus, much of the benefit which may have been derived 
from this practice will be lost, and will with difficulty be regained.*' 

With only slight qualifications I would adopt the advice of Mr. Gran- 
ger. The limb ought, at first, to be placed in a position of semiflexion, 
SO that if anchylosis should unfortunately ensue, it would be in the con- 
dition which would render it most serviceable, and also because in this 
position the muscles which tend to displace the fragment would be most 
completely relaxed. While thus placed, an attempt ought to be made, 
by seizing the epiphysis, to restore it to position ; and if the effort suc- 
ceeds, as it certainly is not very likely to do, a compress and roller 
ought to be so applied as to maintain it in position : provided, always. 
that it shall not be found necessary to apply the roller so tight as to 
endanger the limb, or increase the inflammation. An angular splint 
would be an almost indispensable part of the apparel, at least with chil- 
dren, where this indication is in view. In no case, however, ought more 
than fourteen days to elapse before all bandaging and splinting should be 
abandoned, and careful but frequent flexion and extension lie substituted. 

In three cases seen by me, a displacement of the fragment, either for- 
ward- or backward-, has occurred whenever the arm was flexed, and it 
has been necessary, therefore, to treat the ease with the arm in a straight 
position. These are plainly only exceptions to the rule. 

;i 9. Fracture or Diastasis of the External Epicondyle. (Epicondyle, 
Chaussier.) 

The anatomy of the external epicondyle 1ms already been described 
when speaking of the epicondyles generally. Like the internal epicon- 
dyle, it is composed in pari of an epiphysis, and in part an apophysis 

projected from the shaft of the humerus, which portions become united 

to each other by bony tissue, usually about the sixteenth or seventeenth 
tf life; occasionally the consolidation is delayed much longer. It 
v Bnufll, and serves for the attachment of some of the common 
a of the forearm and hand, and the external lateral ligament. 
Whether this small epicondyh — peaking now of it a- a whole, com- 
posed in part of the epiphysis and in pari of the process from the shafl 
of the humerus — whether this can be broken off or separated ;i~ ;< trau- 
matic accident, ;md a- a simple, uncomplicated fracture, needs no longer 



310 



FRACTUKES OF THE HUMERUS. 



Fig. 



to be discussed. It is plainly impossible, unless the line of fracture in- 
cludes a portion of the joint, and in thai case it is to be designated as a 
fracture of the condyle, and not of the epicondyle. 
At least I may say that no satisfactory clinical 
example, or anatomical specimen, has ever been 
presented. 

It is not difficult to admit, however, the possi- 
bility of a detachment of the epiphyseal portion 
prior to its consolidation with the shaft of the hu- 
merus : and, indeed, the occurrence of such an 
accident would seem quite probable, yet we lack 
any absolutely conclusive evidence that it has ever 
taken place. The specimen sent to me by that 
distinguished anatomist Dr. Zuckerkandl,of Vienna, 
and to whose communications upon this subject I 
have already referred, when speaking of fracture 
of the epicondyles in general, and of the internal 
epicondyle in particular, will not bear the test of 
a critical examination. It was found in the dissect- 
ing-room, and is unaccompanied with any clinical 
history ; but it is evidently from a person near the 
twentieth year of life. There is, indeed, an apparent absence of a por- 
tion of the external epicondyle, and there are two ossicula, situated in 
the external lateral ligament, with smooth, slightly bosselated surfaces. 
Dr. Z. explains the presence of two by supposing it was an exceptional 
process of development; but it is more difficult to explain how the epi- 
physis should have found its way into the lower or distal portion of the 
external lateral ligament, where he correctly states that it is situated. 
The supposed original seat is covered in by perfectly formed lamellated 
tissue, and underneath the situation in which the ossicula are found is a 
deep fossa fitted exactly to receive them. 




Supposed fracture of 
the entire external epicon- 
dyle. 



§ 10. Fractures of the Internal Condyle. (Trochlea, Chaussier, and 
Malgaigne. Internal, Oblique Trochlear Fracture, Denuce.) 

According to the nomenclature which I have adopted, those fractures 
alone which involve the joint can be so designated. They are those 
fractures which, commencing outside of the joint above the base of the 
epicondyle, extend downwards and outwards through the articular sur- 
face of the bone; the condylar fragment carrying with itself more or 
Less of the trochlea, in most cases passing through the olecranon fossa, 
the anterior fossa, and the groove of the trochlea. 

Malgaigne regards the occurrence of this fracture as very rare, and 
declares that he has never seen a case. He admits, however, that it 
happens occasionally, and cites a specimen shown to the Societe Anato- 
mique by M. Gueneau de Massy, in 1837, which had united with the 
fragments in place. 

On the other hand. Sir Astley Cooper, B. Cooper, South, Gurlt, 
and others, speak of it as a frequent fracture, especially in children. For 
myself. I have a record of twenty examples of this fracture seen by 



FRACTURES OF THE INTERNAL CONDYLE. 



311 




myself, while the number of fractures of the external condyle recorded 
by me. is twenty-nine; this difference in frequency being Blight, but a 
little in favor of the external condyle. . 

Causes. — It has already beeu stated that fractures of the internal 
condyle, as well as fractures of the epicondyle, belosg almost exclu- 
sively to infancy and childhood, only two instances 
having come under my notice after the eighteenth Fig. B8. 

year of life. 

I have seen no instance which could he traced to 
any other cause than a direct blow, such as a fall 
upon the elbow, the force of the concussion being 
received directly upon the elbow. M. Pingaud 1 
thinks that even in this case the force applied acts 
indirectly, since it is applied usually to the pos- 
terior and internal surface of the olecranon process ; 
and that the condyle yields to the pressure of the 
crest of the sigmoid cavity of the ulna, supple- 
mented by the tension of the muscles and liga- 
ments attached to the inner condyle. 

Line of Fracture, Displacement, Symptoms. — 
The direction of the line of fracture is tolerably Fracture of internal 
uniform : commencing at or near the centre of the condyle, 

trochlea, it extends obliquely inwards through the 

coronoid and olecranon fossa?, and terminates about one-quarter or half 
an inch above the internal epicondyle. 

Displacement of the lower fragment can take place only in a direction 
upwards, backwards, forwards, and inwards (to the ulnar side). The 
fragment cannot be carried downwards, in the direction of the hand, nor 
outwards, in the direction of the radius, unless the radius also is broken 
or dislocated. 

The most common form of displacement is upward- and backward-. 
and perhaps at the same time a little inwards : the ulna remaining at- 
tached to the lower fragment, ami following its movements. I have 
instance in which the fragment was carried directly downwards 
toward the hand, but this action was originally complicated with a dislo- 
cation of the radius backwards. The dislocation was immediately 
reduced. - after, when the young man was twenty-three years 

old, I found the condyle displaced downwards and forward- about half 
an inch, so that when the forearm was extended it became strikingly 
ted to the radial side. 

The symptoms whicb characterize this fracture are crepitus, almost 

always easily detected ; mobility of the fragment, discovered especially 

zing upon the epicondyle. or by flexing and extending the arm : 

displacement of th<- smaller fragment and ;t projection of the olecranon 

process, this latl _ very marked when the forearm is extended 

upon the arm, bur almost completely disappearing when the elbow is 

: projection of the lower end of the humerus in front when the arm 

tended; the humerus shortened when measured along it- ulnar 



Pingaud, A'- S Hed !1, p. 618. 



812 FRACTURES OF THE HUMERUS. 

from the internal epicondyle; the breadth of the humerus through its 
condyles generally increased slightly, sometimes half an inch or more ; 
if the lesser fragment is carried upwards, it will also be found that when 
the Limb is extended, the forearm A\ill be deflected to the ulnar side. 

Sir Astloy Cooper remarks that it is frequently mistaken for a dislo- 
cation : and Thomas M. Markoe, of New York, has shown that it is, in 
tact, frequently complicated with a dislocation of the head of the radius 
backwards; indeed, he expresses a belief that this dislocation of the 
radius seldom or never occurs without a fracture of the internal condyle. 1 

Results. — It is probable that in a majority of cases no permanent 
displacement exists; although the irregularity of the bony deposits 
around the base of the condyle, wdiich generally may be easily felt, 
would lead to a contrary opinion. The fact that the lower fragment 
usually follows the motions of the olecranon, renders its replacement 
and retention comparatively easy, unless some complication exists. It 
is not from displacement, therefore, so much as from permanent muscu- 
lar, and especially bony anchylosis, that serious maiming so often results. 
Under any treatment bony anchylosis will sometimes ensue, and under 
improper treatment it is almost inevitable. 

Poinsot says, that of five cases reported by Senftleben, only one re- 
covered without anchylosis. In one case where anchylosis resulted, the 
operation of resection of the elbow terminated fatally. 

Treatment. — The arm must be immediately flexed to nearly or quite 
a right angle, when, without much manipulation, the fragments will be 
made to resume their place. A gutta-percha, or felt, right-angled 
splint, such as I have already directed for fractures occurring just above 
the condyles, well and carefully cushioned, may now be applied, and 
secured by rollers. Suitable pads must also aid the splint and roller, 
in keeping the fragments in place. Markoe prefers keeping the forearm 
in a position about ten degrees short of a right angle, believing that in 
this position the ulna itself will act as a splint, and, by its support on 
the uninjured portion of the trochlea, hold in its place the broken con- 
dyle. Very properly, also, he prefers to lay the angular splint, made 
of tin, and fitted to the arm and forearm, upon the back of the limb, in- 
stead of upon the front or sides. If it is upon the inside, it covers the 
broken condyle, and we are unable to know so well its position ; if upon 
either side, it is apt to press injuriously upon the epicondyles; and if it 
is in front, the fragments cannot be so well adjusted or supported. Upon 
this point, however, surgeons are not very well agreed, and no doubt 
more will depend upon the care with which the splint is applied than 
upon the surface against which it is laid. 

Considerable swelling is almost certain to follow T , and no surgeon 
ought to hazard the chances of vesications, ulcerations, etc., by neglect- 
ing to open or completely remove the dressings every day. Within 
seven days, and perhaps earlier, passive motion must be commenced, and 
perseveringly employed from day to day until the cure is accomplished; 
indeed, in many cases it is better not to resume the use of splints after 

1 Aiarkoe, New York Journal of Medicine, May, 1855, p. 382, second series, vol. 
xiv. Also paper read before N. Y. Surg. Soc, May, 1880. 



FEACTURES OF THE EXTERNAL CONDYLE 313 

this period: for, although at this time no bony union lias taken place, 
yet the effusions have somewhat steadied the fragments, and the danger 
of displacement is lessened, while the prevention of anchylosis demands 
very early and continued motion. 

When the fracture is compound, or otherwise complicated, these simple 
rules will seldom be found applicable; indeed, fractures attended with 
no such complications will occasionally be found difficult to reduce, or 
to maintain in position after reduction. 

>j 11. Fractures of the External Condyle. 

It is necessary again to call attention to the fact that the author re- 
cognizes no fractures as fractures of the condyles, either external or in- 
ternal, which do not enter the joint. All not included in this definition 
and occurring in these regions, are epicondylar fractures or diastases. 

Causes. — All the fractures (29) of the external condyle, of which I 
have a record, occurred in children under fifteen years of age, except 
two: one, in which a woman, eighty-eight years of age, fell upon her 
elbow when intoxicated, breaking off the outer condyle. Two months 
after the accident I found the fragment displaced half an inch upwards, 
and firmly united. The other was a man set. 49. 

In a large majority of these cases the patients themselves have af- 
firmed, and the surface of the skin has furnished conclusive evidence, 
that the fracture was produced by a direct blow, generally by a fall upon 
the elbow. 

Line of Fracture, Displacement, and Symptoms. — The direction of 
the fracture is generally such that, commencing at or just within the 
capitellum, or articulating surface upon which the radius is received, it 
terminates above and to the outer side of the external condyle: or, com- 
mencing at the middle of the trochlea, it passes through the olecranon 
and terminates above the condyle, externally. 

It is quite probable that in the latter case, the force which occasioned 
the fracture lias been applied directly to the olecranon, and only indi- 
rectly to the condyle ;i- by Pingaud; but this theory of 
mechanism could not apply to the first class of cases, or those in which 
the lino of fracture is through or just within the capitellum, and which, 
I think, is the most common. It is in these cases especially, the line of 
separation being more superficial, thai the fragment is liable to become 
displaced backwards, forwards, or outwards; generally, 1 have found it 
displaced ;i little outwards, sufficiently to increase manifestly the breadth 
of the condyles, or it has been carried backwards; once slightly for- 
wards; it i- also, in some cases, carried upwards in ;i small degree, 
although the action of the supinators and extensors would Beem t" render 
;i downward displacement more common. Those displacements are 
usually not considerable, and in ;i feu cases there is none at all. Wnat- 
may be the direction or degree in which the fragment is moved, 
however, the head of the radius i- found almost always to accompau 
but in the case which I am about to relate, the head of* the radius became 
complete' I from the condyle. 

Frederick Keaffer, aet. 11. fell from a loud of hay, and he is confident 



314 



FRACTURES OF THE HUMERI'S. 



Fig. 89. 



thai he struck the ground with the back of his elbow. Six hours after 
the accident he was brought to me by the physician who was. first called 
to him. The arm was much swollen, and the external condyle could 
not be distinctly felt; bul when pressure was made directly upon it, crep- 
itus and motion became manifest. The head of the radius was at the 
same time dislocated backwards, and separated entirely from the condyle, 
its smooth, button-like head being very prominent. It is difficult to 
conceive bow a blow from behind should leave the head of the radius 
dislocated backwards, or bow the radius could have separated from the 
broken condyle; but as the examination was repeated several times, and 
while the patient was under the influence of ether, I have no doubt of 
the fact. Several other surgeons who were present concurred with me 
in opinion fully. 

While prosecuting the examination, I reduced the dislocation of the 
radius, but it would not remain in place a moment when pressure or sup- 
port was removed. The lad recovered with a very useful arm, the mo- 
tions of flexion and extension, with pronation and supination, after the 
lapse of a year, being nearly as complete as before 
the accident, the radius remaining unreduced. 

Sometimes it will be noticed that while the por- 
tion of the condyle which is attached to the radius 
falls backwards, its upper and broken extremity 
pitches forwards ; and this attitude it is especially 
prone to assume when the forearm is extended. 

It is even possible, when the fracture traverses 
the trochlea, for the ulna also to become displaced 
backwards along with the radius and the lesser 
fragment. 

Crepitus, which is usually very distinct, is most 
easily obtained by rotating the radius, or by seizing 
upon the condyle with the thumb and fingers, and 
moving it backwards and forwards. 

Results. — Ordinarily, this fragment unites 
promptly, and by the interposition of a bony 
callus ; but in five cases, I have noticed that either 
no union has occurred, or the union has been 
accomplished only through the medium of fibrous structures, and the 
fragment continued afterward to move with the radius. 

As a consequence, probably, of the displacement of the lesser frag- 
ment upwards, the forearm, when straightened, is occasionally found 
deflected to the radial side. The surgeon must not, however, confound 
the deflection which is natural, and which is greater in children than in 
adults, with the unnatural radial inclination which is occasioned some- 
times by this accident. I have met with this phenomenon three times in 
children under three years of age. in one of which I could not discover 
thai the condyle was carried toward the shoulder, but only outwards ; 
in each of the other cases the fragment had united by ligament. The 
following is one of* the examples referred to: 

A girl, ;et. 3, fell and broke the external condyle of the left humerus, 
the fracture extending Freely into the joint ; crepitus distinct; forearm 




Fracture of the exter- 
nal condyle through the 
eapitellnm. 



FRACTURES OF THE EXTERNAL CONDYLE. 315 

slightly flexed : prone. Lesser fragment displaced outwards and a 
little backwards, carrying with it the radius. On the second day I was 
dismissed on account of the unfavorable prognosis which I gave, or 
rather because I refused to guarantee a perfect limb, and an empiric was 
employed. 

July 2. 1857. several months after the accident, the father brought 
her to me for examination. There was no anchylosis, but the lesser 
fragment had never united, unless by ligament, moving freely with the 
head of the radius. When the forearm was straightened upon the arm. 
it fell strongly to the radial side, but resumed its natural relation again 
when the elbow was flexed. 

Two other examples are reported at length, in the second part of my 
Report on Deformities after Fractures, as Cases 57 and 59 of fractures 
of the humerus. 

In one other example, however, mentioned also in my report as Case 
56, the deflection was to the opposite side. I examined the lad one year. 
after the accident, he being then five years old, and I found the external 
condyle very prominent and firmly united, but not apparently displaced 
in any direction except outwards. The radius and ulna had evidently 
suffered a diastasis at their upper ends, but all of the motions of the joint 
were free and perfect. 

Dorsey 1 speaks of this lateral inclination as being always to the ulnar 
side, but does not indicate to what particular fracture of the elbow it 
belongs. He has also described a splint, contrived by Dr. Physick, 
intended to remedy the deformity in question. 

Chelius also speaks of the same deformity as occurring after fractures 
of the internal, but does not mention it in connection with fractures of 
the external condyle, that is. an inclination of the forearm to the ulnar 
side. 

In more than half of the cases of fracture of this condyle some degree 
of anchylosis ha- resulted, lasting at least several months. I have seen 
it remaining after a lapse of from one to twenty years, but generally it 
gradually diminishes, and, in a majority of cases, completely disappears 
af*t»T a few years. 

Tn atment. — I do not know that I need add much to what has already 
beeD said in relation to the treatment of fractures of the opposite con- 
dyle, and at tie- base of the condyles, Bince the measures applicable to 
the ono are, in general, applicable to the other. 

Generally, the forearm ought to be Hexed upon the arm, especially 
with ;i view t<» overcome the usual tendency iii the upper end of the lower 
fragment to pitch forwards, and which form of displacement is greatly 
increased by -t r;i i ltIitcii i jilt the arm. A remarkable exception to this 
rule, and one «.}' two which I have -ecu. must be mentioned. 

James Cronyn, ;iL r ed •'». was brought to me in March, L857, having, ;i 
few minutes before, fallen from ;i height of four or five foot to the ground. 
Hi- father said the elbow had been broken ;it the same point \w<< 
befbrc. and from that time had remained -till' and crooked. I found the 
external condyle broken off. and. with the head of the radius, carried 

1 Elements f Sun PhilipS D Phils, ed. 1818, v.]. i. j, 146. 



316 FRACTURES OF THE HUMERUS. 

backwards. This was the position which it occupied constantly, although 
it was easily restored and maintained in position when the arm was 
straight, bul not by any possible means when the elbow was flexed. I 
dressed the arm, therefore, in an extended position, with a long felt 
splint, and the fragments remained well in place until a cure was accom- 
plished. 

It is especially deserving of notice that, in the five cases in which I 
have observed bony union to fail, and the fragments to continue mova- 
ble, the motions of the elbow-joint have, in a very short time, been com- 
pletely restored. If it does not prove that Granger was correct in his 
view- as applied to fractures of the internal epicondyle, namely, that it 
was of little or no consequence whether the fragment united or not, and 
that the elbow-joint ought to be submitted to free motion from the begin- 
ning to the end of the treatment — if it does not absolutely prove, I say, 
the correctness of his views, it at least must abate our apprehensions of 
the supposed evil results of non-union in the case of the fracture now 
under consideration. 

I shall take the liberty of quoting, also, with a qualified approval, the 
opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris in his 
Report on Surgery, made to the American Medical Association in 1848 : 

"In the treatment of fractures of the condyles of the os humeri, a 
course is usually recommended which he believes to be hurtful, inas- 
much as it favors the worst consequences of the injury, namely, loss of 
motion in the joint. By this mode of treatment, the fractured piece 
becomes sufficiently fixed to create partial anchylosis; and there is so 
much pain afterwards in the proposed passive movements as to cause the 
omission of these measures until permanent stiffness takes place. The 
proper course in the management of these accidents, he conceives to be 
— 1st. To apply no splints, but in the earlier days to make use of the 
proper means to prevent inflammation. 2d. To accustom the patient to 
early and daily movements of flexion and extension. 3d. When the 
action of the joint becomes limited, to overcome the resistance by force, 
and repeat it daily until the tendency of the joint to stiffen ceases. 

" The accomplishment of this process, he adds, is so very painful that 
few patients have courage to submit to it, and few surgeons firmness to 
prosecute it. The consequence has been that in a great number of cases 
the use of the articulation to a greater or less extent has been lost. The 
introduction of etherization, by preventing the pain, gives us, in the 
opinion of Dr. Warren, the means of overcoming the resistance. By its 
aid lie has restored the motion of a considerable number of anchylosed 
elbows, and has successfully applied the same measures to other joints, 
particularly to the shoulder and knee. This has now become his settled 
practice, with the results of which he is entirely satisfied. The inflam- 
mation consequent upon the forced movements of an anchylosed joint is 
not to be lost sight of. By a reasonable abstraction of blood, and other 
anti-inflammatory treatment, he has never found it alarming." 1 

My respect for the distinguished surgeon whose opinion is here given 
doc- not permit me to question the correctness of his practice; but I 

1 Transactions of the American Medical Association, vol. i. p. 174. 



FRACTURES OF THE LOWER END OF HUMERUS. 317 

cannot avoid a belief that his language does not convey a precise idea 
of his views. If lie intends to say that he would move the joint freely 
when it is suffering from acute inflammation, and when motion occasions 
great pain, I must protest against the practice as likely to do vastly 
more harm than good in any case: but if he would move the joint from 
the first, when the inflammation and swelling are trivial, and when it 
occasions only a moderate amount of pain, then his views are just, and 
his practice worthy of imitation. 

§ 12. Fractures of the Articular Processes of the Lower End of the 
Humerus ; wholly within the Capsule. 

Three examples illustrating this variety of fracture have been referred 
to by Stimson. 1 The first was seen by Laugier, 2 in the person of a girl 
seventeen years old, who had fallen upon her hand. It was not followed 
by swelling or by effusion within the joint. Laugier considered it a 
fracture of the trochlea alone. The treatment consisted in rest, the 
forearm being slightly flexed and pronated. In a few weeks recovery 
took place, with complete restoration of the functions of the arm. 

The second case is from Gurlt, 3 a museum specimen, without history. 
It is an adult bone. The trochlea and capitellum are broken off and 
displaced forwards and upwards, and have re-united with the bone above 
the coronoid fossa; the articular surfaces being still covered with carti- 
lage. 

The third 4 is that of a woman, set. 67, who having received an injury 
upon her elbow, the surgeon diagnosticated a fracture of the neck of the 
radius ; but the patient having died four years later, the capitellum was 
found broken off and displaced : having reunited with its upper border 
resting in the radial depression (fovea minor). The head of the radius 
was not broken. 

The same difficulties present themselves here as in the supposed ex- 
amples of intracapsular fractures of the head of the humerus. In the 
clinical example related by Laugier, the exact line could not have been 
absolutely determined. And this difficulty is illustrated by the third 
case, in which the clinical diagnosis was greatly at fault. The third 
also, where an autopsy was made after four years, can only be re- 
garded as furnishing conclusive evidence that the capitellum was broken; 
inasmuch as the changes in its form and size, caused by absorption, as 
we have seen happens in intracapsular fractures of botb the heads of the 
humerus and femur, must render it difficult to say thai the line of frac- 
turewasnot outside of the capsule. The second case was a museum 
men, unaccompanied with a history, and for the same reason there 
can be no conclusive evidence thai it was intra-articular. Whenever we 
find a recent accident, in which the autopsy shall -how thai the line of 
fracture was wholly within the capsule, the testimony will be conclusive. 
At present this kind of testimony is wanting. 

■ • on Fractures, p. H8. 
\ roh. (x'u. de li< d., 1858, v. i. p. 46. 
>. Knochenbruchen, vol. 2, p 
* Q irlt, op. <■ •.. vol 2, p. 881. 



318 FRACTURES OF THE RADIUS. 



CHAPTER XXII. 

FRACTURES OF THE RADIUS. 

Of one hundred and twenty-seven fractures of the radius which have 
beeD recorded by rne, not including gunshot fractures, or fractures de- 
manding immediate amputation, three belonged to the upper third, ten 
to the middle third, and one hundred and fourteen to the lower third. 
Of those belonging to the lower third seven were through the shaft, 
more than two inches above the lower end, two were fractures of the 
styloid processes, and the remainder, one hundred and five, were Colles's 
fractures. Five were compound, and one hundred and twenty-two sim- 
ple. Sixty-nine are reported as occurring in males, and fifty-eight in 
females ; sixty-one as having occurred in the left arm, and forty-one in 
the right. 

Fractures of the TJjpjper End. 

a. Fractures of the Head. — Most of the fractures of the head of the 
radius which have been satisfactorily demonstrated, were longitudinal or 
nearly so. 

I have seen in Dr. Mutter's collection two specimens of fracture of 
the outer half of the head of the radius. In one the small fragment is 
slightly displaced downwards in the direction of the axis of the bone ; 
and in the other the fragment is thrown outwards, or to the radial side. 
Both are firmly united in their new positions. 

Stimson says, in his treatise on Fractures, that he met with two cases, 
in one of which the injury was the result of a direct blow, and the other 
was accompanied with a dislocation of the radius and ulna backwards. 
In both cases he practised resection, but he does not say with what re- 
sult. He has seen, also, one other case treated by Dr. Townsend, of 
Bellevue Hospital, in which one year after the accident the fragment 
remained movable, but the motions of the joint were completely restored. 

Bruns 1 has collected twenty-two cases of longitudinal fracture of the 
head, recorded or observed by Hodges, 2 Verneuil, 3 Flower, 4 Gross, 5 
Gurlt, 6 Weichselbaum, 7 Lesser, 8 Hiiter, 9 and himself, respectively. Mal- 
gaigne has also mentioned one. 10 

According to J>nins. this fracture "may be incomplete, and then the 
fissure may be single or multiple. When it is complete, a fragment of 

1 Bruns, des frak. des radius kopfchens, Centralblatt fur Chir., 1880, No. 22, pp. 

568. 

Bodges, Bost. Med. and Surg. Journ., Dec. 6, 1866, p. 383, and 1877, p. 65. 

Verneuil, Jajavay, Frac. des Artie, These d'agreg., Paris, 1851. 
1 Flower, Bolmes's Surg., vol. 2, 2d ed., p. 791. 
■ Gross'a Surg., 1869, p. LSI. 

8 Gurlt. Bandbuch der Lehre von den knoch., 2d theil, Berlin, 1865, p. 810. 
7 Weichselbaum, Virchow's Arch., Bd. 57, p. 127. 
" Lesser, Deutsche Zeit>chrift fur Chir., Bd. 1, p. 292. 

Buter, Verhandl, der Deutschen (xesellschaft fur Chir., V. Kongress, 1876, p. 39. 
10 Bfalgaigne, Poinsot, op. -it.. ]>. 332 et seq. 



FRACTURES OF THE HEAP OF THE RADIU! 



319 



Fig. 90. 



the anterior border is generally found separated from the bone : at times, 
then, the fracture is entirely intra-artieular. and the fragment of bone 
is loose in the interior of the joint: at others it extends beyond the ar- 
ticulation, and the fragment may be held in place more or less by the 
annular ligament. 

"Fracture of the head of the radius maybe isolated (li\ e times out of 
twenty-two cases), but more often it is complicated with lesions of the 
neighboring bones (four times with fracture of the external condyle, 
three times with fracture of the olecranon, of the coronoid process, and 
of the neck of the radius, twice with fracture of 
the olecranon and the coronoid process, twice 
with a fracture of the coronoid process and a dis- 
location of the forearm, once with fracture of the 
shafts of the humerus and ulna and dislocation of 
the radius forwards). As may be seen, the most 
frequent complication is fracture of the coronoid 
process. 

"Although fracture of the head of the radius 
is sometimes produced by a. direct injury, it is 
most frequently the result of an indirect cause, 
such as a fall upon the hand, the arm being ex- 
tended; in this position, indeed, the external 
condyle comes in contact only with the anterior 
part of the head of the radius. This fracture 
sometimes occurs when the forearm is in a state 
of extreme flexion; in such case it is probably 
the result of violent contact of the anterior border 
of the head with the anterior surface of the 
humerus. ' ' — Painsot. 

The diagnosis of this accident is in many cases 
difficult Occasionally, when the fracture is com- 
plete, a movable fragment may be recognized, 
with crepitus; and in other cases its existence 
may. perhaps, be inferred from the increased 
breadth of the head of the radius, the condition 
simulating a partial dislocation forward.-. 

Brun- Bays that out of Beveu observations 
where the results could be established, three times 
bony consolidation occurred, once the fragmenl 
united by callus to the coronoid process, and 
times the isolated fragment finally became 
a truly foreign body in the articulation. Biiter, 
in his bliged to resort to arthrotomy in 

order to extract this foreign body of ;t new kind. 
Kofuiohl 1 affirm- that ;i Longitudinal fracture of tin- bead of* the radius is 
more common in childhood than in adult life, he having net with §< 
teen cases in ;i total of fifty-two fractures of the forearm, and tweli 
the subjects irere from one to four years of age. Be Btates, moreover, 

1 Kofrnohl. Ueberden intrakap., Brucfa dea radius, e, No. 

12 ; p. 



f 



Fracture of head <>f ra- 
dius. (MUtter 1 * Collection. 
Specimen \. X". 105.) 



820 FRACTURES OF THE RADIUS. 

that it is caused most often by lifting the child by the arms; that the 
pain accompanying the accident is usually felt at the wrist, and that the 
results are of the simplest kind, the functions of the limb being com- 
pletely restored in from three to four weeks. In my opinion, these 
statements o\' Kofmohl ought to be received with much hesitation. 

In regard, to the treatment of this fracture, in case it be recognized, 
it would seem that it ought to be directed chiefly, as in most other frac- 
tures involving joints, to the prevention of anchylosis, by careful but 
persistent motion of the joint by flexion and rotation. The result might 
be a fibrous union, or perhaps non-union and necrosis of the fragment; 
but even this latter result would be no more serious than a permanent 
anchylosis. Stimson, however, who seems to regard union of the frag- 
ments as the most important indication, recommends immobilization; 
the question of the position of the arm, and the general management, 
being left to the discretion of the surgeon in each particular case. It is 
probable, however, that in most cases a more or less flexed position of 
the arm, with supination, will insure the most satisfactory results. In 
case anchylosis were to result, the flexed position, at a right angle, would 
give the most useful arm. 

b. Fractures of the Neck. — Fracture of the neck of the radius, as a 
simple accident, uncomplicated with any other fracture or dislocation, is 
exceedingly rare; yet, owing to the depth of the superincumbent mass 
of muscles, and the difficulty of determining, where so many bones and 
processes approach each other, precisely from what point the crepitus, if 
any is found, proceeds, surgeons have often been deceived, and they have 
believed that they were the fortunate possessors of this rare pathological 
treasure, when the autopsy has too soon disclosed their error. Both B. 
Cooper and Robert Smith have alluded to this difficulty, and the case 
reported by Dr. Markoe to the New York Pathological Society, and 
published in the American Medical Monthly, will serve to illustrate the 
same point; in which case the signs of a fracture of the radius at its 
neck were such as to deceive that experienced surgeon, yet the autopsy 
disclosed the fact that it was a dislocation of the head of the radius 
forwards, with a fracture of the ulna. Indeed, its existence as a form 
of fracture was doubted by Sir Astley Cooper, and by others has been 
actually denied. I have seen no specimen obtained from the cadaver, 
except the doubtful one contained in Dr. Watt's cabinet, and of which I 
have furnished an account, accompanied with a drawing, in my report to 
the American Medical Association, 1 and the specimen owned by the late 
Dr. Miitter. of Philadelphia, of which he has kindly furnished me the 
following description: "History unknown. The line of fracture seems 
t-» have passed through the neck of the left radius, just at the upper 
extremity of the bicipital protuberance. Union with deformity has 
resulted. Owing to the fracture having taken place within the inser- 
tion of the biceps, that muscle appears to have dra^vn forward and 
upwind the lower end of the short upper fragment. In consequence of 
tlii< movement, the articulating facet of the head of the radius is tilted 
backwards, so as no longer to be in contact w r ith the humerus. As a 
secondary consequence, the anterior edge of the head of the radius rests 

1 Transactions, vol. ix. pp. 157, 229. 



FRACTURES OF THE XECK OF THE RADIUS. 



321 



Fig. 91. 



permanently against the articulating surface of the humerus. At this 
new point of contact a new surface of articulation is seen to have been 
formed, while the original articulating facet is 
directed hack wards, and lies at right angles 
to the one of more recent formation. At the 
inner edge of the new articulation of the head 
of the radius with the humerus, contact with 
the ulna has developed another surface of ar- 
ticulation. The upper and lower fragments 
are united at an angle, and the radius does 
not appear to have lost in length.' ' 

Velpeau has once demonstrated the exist- 
ence of this fracture in a dissection, but the 
fracture was accompanied with a fracture 
also of the coronoid process: and Berard 
obtained possession of a similar specimen. 
I do not remember to have seen a notice of 
any others. Malgaigne affirms, with his usual 
frankness, that although he has occasionally 
believed that he had met with it, the autopsy, 
whenever it has been obtained, has shown 
that it was rather a subluxation than a frac- 
ture. On the other hand, Mr. South calls it 
a "not unfVequem accident." but in confirma- 
tion of this declaration he cites no examples. 

While, therefore, the presence of what ap- 
pear to be the rational diagnostic signs has 
compelled me to record one case as an uncom- 
plicated fracture of the neck of the radius, 
and two others as fractures at this point accom- 
panied either with a fracture of the humerus 
or a dislocation of the ulna. I am prepared to admit that some doubt 
remains in my own mind as to whether in either case the fact was 
clearly ascertained; nor do I think, speaking only of the simple frac- 
ture, that it will ever be safe to declare positively that we have before 
us this accident, lest, as has happened many times before, in the final 
appeal to that court whose judgment waits until after death, our decisions 
should bo reversed. 

Nothing, perhaps, could more fully illustrate the difficulty of diag- 
eceived in the neighborhood of the head or 
<»f the radius than the testimony given in the case of Nbyes p«. 
Allen, tried in the Supreme Court at Cambridge, .January. L856, before 
Judge Bigelow. Mr. Novo- injured his elbow. January 7. 1854, ami Dr. 
Allen, who was called immediately, believed that the Ligaments of the 
joint had been torn, but that no bones were broken or displaced. On 
the following morning he was dismissed, and Mr. Noyee went home. 
Three week- later ir was seen by Dr. \><>w. who also thought then 
no fracture. About er tie- accident a physician examined 

the arm. and dor-hired the nock of tie- radius broken, and th<- fragments 
displaced; and when the - finally brought to trial he testified 

L'l 




Fracture of neck of radius 
(Mutter's cabinet), a. Original 
articulating facet, b. New ar- 
ticulating facet, c. Projecting 
fragments. 



o-2-2 FRACTUKES OF THE RADIUS. 

-till that such was certainly the fact; and five other physicians, not one 
of whom, however, we are told, was a member of the State Medical 
Society, testified positively that the radius was broken at its neck, pro- 
ducing a bony protuberance; that such an injury only could account for 
the symptoms manifested at the time of the accident, and that no other 
fractures or injuries of the joint could explain so well the present ap- 
pearances of the arm. "While, on the part of the defence, six of the most 
intelligent medical gentlemen of the State, Drs. Kimbal and Huntington, 
of Lowell, and Drs. Townsend, Lewds, Clark, and Gay, of Boston, tes- 
tified that the head and neck of the radius were not displaced, nor w r as 
there any evidence that this bone had ever been broken. There is every 
reason to believe that these latter gentlemen were correct ; yet it is to be 
presumed that the gentlemen who first testified were not without some 
grounds for their opinions so confidently expressed. 

The case was given to the jury after a trial of five days, who promptly 
returned a verdict for the defendant. 1 

"When the fracture occurs, the upper end of the lower fragment will 
probably be carried forwards by the action of that portion of the biceps 
which has its insertion into the tubercle; and the displacement in this 
direction must necessarily be increased in proportion as the arm is 
straightened. In the cabinet specimen belonging to Dr. Mlitter (Fig. 91), 
the line of fracture, commencing in the neck, has terminated in the 
tubercle; consequently the biceps, having still some attachment to the 
upper fragment as well as the lower, has drawn them both forwards. 

The same anterior displacement I have noticed in all of the supposed 
living examples, but whether both fragments or only one had suffered 
displacement I am unable to say. 

A girl, get. 11, living in Ontario Co., N. Y., fell from a tree, and in- 
jured her right arm. Her surgeon, who regarded it as a fracture of the 
neck of the radius, reduced the fragments, and placed the forearm at a 
right angle with the arm. On the twenty-eighth day all dressings 
were removed, and the patient was dismissed, the fragments seeming to 
be in place. The parents, finding the elbow stiff, now made violent and 
successful efforts to straighten the arm. 

Fifteen months after the accident, the child was brought to me. 
There was at this time a bony projection in front, opposite the neck of 
the radius, which I believed to be the point of fracture. The hand was 
forcibly pronated, and she had only a limited amount of motion at the 
elbow-joint. The anchylosis was probably due to inflammation directly 
resulting from the severe contusion ; but it is quite probable that the 
forward displacement of the fragments was alone due to the too early 
and too violent attempts to straighten the arm; at least, this was the 
explanation which I ventured to give to the parents at the time. 

The second case occurred in a lad eight years old, living in Wyoming 
Co., N. Y. His parents brought him to me ten weeks after the injury 
was received, and I then found the forearm bent to a right angle with 
the arm, and anchylosed at the elbow-joint. The hand was also forcibly 
pronated, and could not be supinated. In front, and opposite the neck 

1 Amor. Med. Gazette, vol. vii. p. 299. 



FRACTURES BELOW INSERTION OF THE BICEPS. 323 

of the radius, there was a distinct bony projection, which I believed to 
be the point of union of the bony fragments. The external condyle 
seemed also to have been broken. 

The third example, treated originally by Dr. Nott, of Buffalo, was 
seen by me six months after the accident. The upper end of the lower 
fragment seemed to be displaced forwards. There was very little motion 
at the elbow-joint, and both pronation and supination were completely 
lost. 

In the treatment of fractures of the neck of the radius, we must not 
neglect to flex the forearm upon the arm, so as to relax, as completely as 
possible, the biceps, whose advantageous insertion into the tubercle of the 
radius would be certain to produce displacement, unless this position was 
adopted. A single dorsal splint, properly padded, should support the 
forearm, while the surgeon, having placed a compress over the upper end 
of the lower fragment, proceeds to secure the whole with a roller. 

Especial care must also be taken to prevent the forearm from being 
extended before the bony union is fairly consummated, lest the biceps, 
now firmly contracted, should draw the lower fragment forwards, as it 
must inevitably do while the bony union is imperfect; an accident 
which, there is some reason to believe, occurred in one of the examples 
which I have already cited. 

If the patient be a child, or if there is any reason to suppose that 
these rules will not be faithfully complied with, it would be well to 
secure the arm in this position with a right-angled splint. 

Fractures below the Insertion of the Biceps, and above the Insertion 
of the Pronator Radii Teres. — When the fracture occurs at this point, 
Mr. Lonsdale suggests the propriety of placing the forearm in a con- 
dition of supination, at least so far as practicable, for the purpose of 
securing a proper apposition of the fragments. His argument in favor 
of this practice is ingenious, and deserves consideration. 

When the bone is broken anywhere in this portion, the action of the 
pronators upon the upper fragment ceases ; while that of the biceps, 
which is a powerful supinator, continues; consequently the upper frag- 
ment becomes at once, and completely, rotated outwards or supinated. 
Now, if the hand, to which the lower end of the radius alone remains 
attached, should be forcibly pronated, the radius will also be rotated 
inwards upon its own axis; and although it might be possible in this 
condition to bring the broken ends into contact, and a bony union, with- 
out deformity, might he consummated, yet the power of supination must 
be forever lost: since the union has been effected while the head ami 
upper fragment are already in ;i Btate of complete supination ; and if 
such is the fact, it is evident thai the whole bone, together with the 
hand, will be incapable of any further supination. 

It is not. indeed, the practice with any surgeons, bo far a- I know, to 
treat this fracture with the hand placed in a position of extreme prona- 
tion; but the case has been supposed \'<>v tin- purpose of rendering the 
argument more intelligible. The usual practice is t<> place the forearm 

and hand in a position midway between Supination and pronation, and 

then to lay it across the body at a right angle with the arm ; hut it is 
plain that the same objection, differing only in degree, will apply to this 



324 



FRACTURES OF THE RADIUS. 



position as to that of pronation. The axes of the two fragments are not 
made to correspond, since, while the lower fragment is only half rotated 
outwards, the upper fragment is completely, and the result of the union 
must be the loss of one-half the power of supination in the hand. 

It is only, then, by complete supination of the hand during treatment 
that this difficulty can be avoided, and I have no doubt that we ought to 
adopt this plan, whenever it is practicable to do so, or whenever we are 
not hindered by serious obstacles; and the only obstacle which occurs 
to me as likely to interpose itself, is the practical one which most sur- 
geons must have experienced in treating all injuries of the forearm, 
whether fractures, or only severe contusions of the muscles, etc., namely, 
the constant and almost uncontrollable tendency of the hand to assume 
the prone or semi-prone position. This is due, no doubt, to the great 
preponderance of power in the pronators ; and such is the resistance 
which they afford to supination that it is often quite impossible to lay 
the hand upon its back while the forearm is across the body, and, if 
accomplished, the position generally becomes in a few hours so painful 
as to be intolerable. By extending the arm, however, and laying it 
upon a pillow, the hand will be found again to rest easily upon its back, 
because in this way we avail ourselves of the outward rotation of the 
humerus at the shoulder-joint. 

Dr. X. C. Scott, formerly Resident Surgeon to the Brooklyn City 
Hospital, in his inaugural thesis, submitted in March, 1869, has dis- 

Fig. 92. 




Scott's apparatus for fractures of the forearm. 

cussed very fully the advantages of this position in many fractures of 
the forearm, and he lias devised a very ingenious mode of securing the 
limb after supination is effected, adding also a moderate amount of ex- 
tension by adhesive plasters and elastic bands. 

Dr. Scott inform- me that he has treated twenty-five cases very suc- 
cessfully at the Brooklyn City Hospital and elsewhere, by this method. 

Fractures of the Shaft. — It has already been stated that of the whole 
number of fractures of this hone recorded by me, amounting in all to 
127. only 10 belonged to the middle third; an observation which is in 



FRACTUEES OF THE SHAFT OF THE RADIUS. 325 

striking contrast with the remark of Chelius. that it is broken most 
frequently in its middle. 

If the fragments are completely separated in the middle third, the 
lower end of the upper half is drawn forwards by the action of the biceps 
aided by the pronator radii teres, in case the fracture is below its inser- 
tion; while the lower fragment is tilted toward the ulna by the conjoined 
action of the supinator radii longus and pronator quadratus. But as to 
the direction of the displacement, much will depend upon the direction 
of the force by which the fracture has been occasioned. 

A laboring man, jet. 35, broke the radius near the lower end of the 
middle third. On the same day I replaced the fragments as well as I 
could in the midst of the swelling which had already occurred, and 
applied two broad and well-padded splints, one to the palmar and one to 
the dorsal surface of the forearm. 

On the twenty-eighth day I first discovered that the fragments were 
projecting in front, and I at once proposed to thrust them back by 
force, but the patient declined allowing me to do so. I then applied a 
compress near the summit of the projection, but not exactly upon it, 
lest it should cause ulceration, and secured over this a firm splint. At 
first this seemed to produce a change in the fragments, but after a 
couple of weeks I found there was no improvement, and it was discon- 
tinued. About six months after the fracture occurred, this man had 
the same arm terribly lacerated in a railroad accident, and I was 
obliged to amputate near the shoulder-joint; and I thus obtained the 

Fig. 93. 




Fracture of the shaft of the ra<lius. (From Gray.) 

broken radius. 'Dm- hone was firmly united, but with an angle, salient 
forward-, of about ten degrees. There was no Inclination toward the 
ulna. 

My impression is that these fragments were never completely re- 
placed, a point which I could not well determine at firsl on account of 
the rapid effusion. \i' they bad been, I think they could have been 
retained in place with the appliances used. Almost every day the limb 
was examined, and a- often a- every fourth or fif'tli 'lav the dress 
were removed and carefully reapplied. And only one-- di.l they become 
so loose as not to afford the requisite support, and tlii- at a period too 
late to have occasioned the deformity. 

Wo ought not to bo deceived, therefore, and promise too confidently 
a perfect limb, even when but tie- radius i- broken, since we may aol 
always be certain that the ends an- well replaced, or perhaps they may 



326 FRACTURES OF THE RADIUS. 

become displaced subsequently, and in either case Ave are not likely to 
discover the deformity until the swelling has subsided, and it is too late 
to apply the remedy. 

In the treatment of fractures of the middle third, the same rules, 
with only slight modifications, will be applicable, as in fractures of 
both bones. Two straight, long, and broad splints must be applied 
after being carefully padded; and especial attention should be paid to 
the tendency of the fragments to become displaced forwards and toward 
the ulna through the action of both the biceps and the pronator radii 
tores: a tendency which may in some measure be provided against by 
flexion of the arm, but which must be overcome chiefly by steady and 
well-adjusted pressure, near, but not upon, the ends of the fragments. 

Fractures of the Lower End, — Fractures of the lower third, occur- 
ring above the line of Colles's fracture, are almost as rare as fractures of 
the middle or upper third. I have recorded seven ; one of which it will 
be proper to relate as a representative example : 

George Vogel, set. 30, was admitted to the Buffalo Hospital of the 
Sisters of Charity, Nov. 2, 1852, with a fracture of the right radius 
about three and a half inches above its lower end. The hand was prone, 
and inclined to the radial side ; while the broken ends of the radius fell 
against the ulna, from which it was found difficult to separate them. 
The lower end of the ulna was prominent, and projecting upon the ulnar 
margin of the hand. 

I was unable completely to separate the fragments of the radius from 
the ulna, by either pressure with my fingers between the bones, or by 
seizing upon them with my thumb and fingers. Having, however, 
adjusted them as well as possible, I flexed the arm, and applied a broad 
and well-padded splint to the palmar surface of the forearm, securing 
it in place with a paste bandage. These dressings were finally removed 
at the end of four weeks, when I found scarcely any displacement or 
deformity remaining. 

Most of these fractures of the shaft in its lower end, when properly 
treated, result in perfect limbs. In a certain proportion, however, it 
will be found impossible effectually to resist the action of the pronator 
radii teres and of the quadratus, and the fragments will unite at an angle 
resting against the ulna, and sometimes, by the interposition of inter- 
mediate callus, they will become firmly united to the ulna. Occasion- 
ally, also, especially where the fracture has been produced by a fall upon 
the hand, and the radio-ulnar ligaments of the wrist have been torn or 
stretched, the lower end of the ulna will be found to project permanently, 
and the hand to fall more or less to the radial side. In examples of this 
kind, of which I have seen one or two, the cause and, to some degree, 
the manner of the displacement are such as to entitle them perhaps to be 
regarded as true Colles's fractures; but we have found it convenient to 
restrict the use of this title to fractures occurring within at least one inch 
and a half of the joint. 

Colles's Fracture. 

I have retained the name " Colles's fracture," so long in use by 
English-speaking surgeons, for the reason that it is familiar to most of 



C0LLE6 S FRACTURE. 



327 



my readers, although it is now well known that Pouteau first described 
this accident. 1 Of the one hundred and fourteen fractures belonging to 

the lower third of the radius, one hundred and live were near the Lower 
end, or within from half an inch to one inch and a half from the articular 
surface: all. except two styloid fractures, being included in that class 
known as " Colles's fractures."* most of which were no doubt true frac- 
tures, and probably a small proportion separations of the epiphyses. 

Etiology and Anatomy of Colles's Fracture. — In every instance, ex- 
cept one. which has come under my notice, where the cause of a ('olio's 
fracture has been ascertained, it has been occasioned by a fall upon the 
palm of the hand. The exceptional case was in the person of Mrs. D. 
B.. who fell in getting out of a street-car in the city of New York, May 
:2<». 1865, striking upon the back of her hand while the hand was shut. 
The displacement was in the same direction as in cases caused by a fall 
upon the palm. Robert Smith has seen a similar accident cause a dis- 
placement of the fragment forwards. I shall refer to the etiology or 
mechanism of this accident again farther on. 

Colles described the fracture as occurring always about one inch and a 
half above the carpal end of the bone: 2 but Robert Smith, who has care- 
fully examined all of the cabinet specimens he could find, about twenty- 
three in number, has never seen the line of fracture removed farther than 
one inch from the lower end of the bone, and in several specimens it was 
within one-quarter of an inch of this extremity. Dupuytren has also 
described the fracture as occurring from three to twelve lines above the 
joint. 

M. TrMat 3 thinks that in the fractures of old people the line of sepa- 
ration is ordinarily quite at the inferior extremity of the bone. 

Fig. 94, 




Fracture of the radius near it.- lower end. Colles'fl frs 



I ontrary to the opinion of Sedillot and Euel, M. Voillemier affirms 
that, instead of being oblique, nerally been supposed, the frac- 

ture is almost uniformly transverse from the palmar to the dorsal surfaces 
of the bono, and only occasionally -lightly oblique in its other diameter, 
or from tie- radial to the ulnar side. I have Been, however, in the mu- 
seum of the College of Physicians of Philadelphia, ;i specimen of this 
fracture in which tie- line of fracture is tri from side to side, hut 

oblique from before backwards, and from below upwards. Thi 

1 Pouteai Baton, Chir. Tat), 

2 Colles, Ed. Med. and SurL'. Journ., vol. t. p. 182, 

3 Trelat, Jour: de Chir. Prat, 1877, A.vriL 



328 FRACTURES OF THE RADIUS. 

also a line of incomplete fracture extending into the joint. It is united 
by bone, with the usual displacement backwards ; and there are several 
similar specimens in the New York Hospital museum. My own cabinet 
contains two such examples. It is my opinion, therefore, that the direc- 
tion of the line of fracture described by Voillemier is exceptional. 

The observations of both R. Smith and Voillemier have shown, more- 
over, that the displacement of the lower fragment is seldom sufficient to 
enable it to escape completely from the upper; and that where, in ex- 
tremely rare instances, and in consequence of extraordinary violence, 
such complete separation does occur, a disruption of those ligaments 
which attach the lower fragment to the ulna occurs also, and the de- 
formity becomes at once very great, so that it no longer presents the 
peculiar features of Colles's fracture, but resembles a dislocation. 

In Colles's fracture, the lower and outer border of the radius, or its 
styloid apophysis, is swung around or tilted, as it were, upon the ulna ; 
the lower and inner border of the same fragment being retained in place 
by the radio-ulnar and internal lateral ligaments, which do not usually 
suffer a complete disruption, but only a stretching or partial laceration, 
possibly by the triangular ligament or by some of its untorn fibres, and 
by one fasciculus of the anterior annular ligament, which is probably 
seldom torn. The upper or broken margin of the lower fragment, and 
also the ulnar margin, undergo very little displacement ; while the lower 
or articular surface, and the radial margin, are carried backwards, up- 
wards, and outwards. 

Surgeons have spoken of a falling in of the upper end of the lower 
fragment toward the ulna, as an almost inevitable result of the action of 
the pronator quadratus, and against which tendency they have sought 
carefully to provide ; but there is much reason to believe that any con- 
siderable degree of displacement in this direction is a rare event, and 
that, when it does exist, it is in consequence mostly of the direction of 
the force which has produced the fracture rather than of the action of 
this muscle, only a few of the fibres of which are usually attached to 
the lower fragment, and, in some instances, when the fracture is within 
a half or quarter of an inch of the articulation, not any. Besides, there 
is actually in these latter cases no interosseous space into which the 
fragments may fall, and its displacement toward the ulna becomes, there- 
fore impossible. 

Still, however, if one were disposed to speculate upon the condition 
of these parts after the fracture, it might perhaps be easy to persuade 
ourselves that the action of the pronator quadratus upon the upper 
fragment, whose broken extremity was not completely, or at all, disen- 
gaged from the lower, would carry both fragments together toward the 
ulna. But whatever might be the result of our speculations, still the 
fact, as proved by specimens, is not generally so; and this is not the 
first time that facts and theories have disagreed. 

The truth is, that it is unusual to find any of the museum specimens 
of this fracture thus united. But they may be found constantly tilted 
back in the manner 1 have described, occasionally tilted forwards, and, 
still more rarely, slightly displaced upon their broken surfaces antero- 
posteriorly. 



COLLES'S FRACTURE. 329 

The general absence of this internal displacement may find its ex- 
planation in the direction of the force which generally produces this 
fracture, in the occurrence of the fracture sometimes at a point so low 
as to render its displacement in this direction impossible, and in the 
breadth of the bone, at the seat of the fracture, which does not permit 
it to fall laterally without actually increasing its length : a circumstance 
which its secure ligamentous attachment to the ulna at its opposite ex- 
tremities, and its complete apposition to the wrist and elbow-joint, do 
not allow. 

The mistake of those surgeons who have attempted to describe this 
fracture has originated in the appearance presented in nearly all recent 
fractures occurring at this point. The hand falls to the radial side, and 
seems to carry the lower end of the lower fragment with it. while the 
lower end of the ulna becomes unnaturally prominent in front and to 
the ulnar side : a condition of things which has naturally enough been 
ascribed to the displacement of the upper end of the lower fragment in 
the direction of the interosseous space. 

But this same radial inclination of the hand, and prominence of the 
ulna, are present frequently when the radius is broken at its lower end, 
and no displacement in any direction has taken place; and I have even 
observed it in simple sprains of the wrist, and in the hands of old or 
feeble persons where all the ligaments have become relaxed. 

It is seen, however, in a more marked degree when the bone is actu- 
ally b<»th broken and displaced backwards in its usual direction. In 
short, the deformity in question Is due. in a large majority of instances, 
to the relaxation, stretching, or more or less disruption of the anterior 
and posterior radio-ulnar ligaments, the triangular fibro-cartilages, and 
the internal lateral ligaments ; to which, I feel satisfied, we must add the 
influence of the strong and unbroken oblique fasciculus of the anterior 
carpal ligament. It i- probably dm- to one or all of these circumstances 
combined that the hand falls to the radial Bide by a sort of rotatory mo- 
tion, of which the unbroken external lateral ligaments and the strong 
fasciculus of the anterior ligament constitute the axis or centre of motion. 
For this reason, also, because these triangular, interna], and radio-carpal 
ligaments once lengthened or broken can uever, or only after ;i lapse of 
many years, be completely restored, this deformity may be expected, in 
a certain number of cases, to continue, however exact and perfect may 
be the bony union. 

It D led. however, that SO long as the tilting of the fragment 

remain.-, the articular surface is actually presenting somewhal to the 
radial side. While in the normal condition it presents downwards, for- 
wards, and inwards, it now presents, when the displacement i- consider- 
able, downwards, backwards, and out? 

Diday maintained that then- existed usually in this fracture an over- 
lapping or shortening of the bone in it- entire diameter, and \ oillemier 
thought that Ti bich he hud examined proved thai an 

impaction was almost universal, and Tillaux has observed it frequently. 

Both of these opin • Smith has sought to combat, declaring 

that the appearance of impaction is due to the ensheathing callus, w bich is 
deposited usually, if the displacement is allowed to continue, in the re- 



330 



FRACTIKES OF THE RADIUS. 



tiring angle opposite the seat of fracture. Jajavay and Fouchat sustain 
the observations of Smith, but some recent observations made by Mr. 
Callender, o\' Saint Bartholomew's Hospital, London, go far to support 
the opinion that some impaction generally exists, but rather upon the 
posterior margin than upon either the radial or ulnar side; 1 and my 
own observations lead me to conclude that a posterior impaction is quite 
common. 

In a case reported by Dr. Cameron, of Glasgow, resulting in speedy 
death, the impaction was complete posteriorly, and was accompanied 
with impaction and comminution of the lower fragment, while the frac- 
ture in front was tk hardly complete, the periosteum holding the fragments 
together." 2 

Comminution of the lower fragment has never occurred in the experi- 
ments made by me upon the cadaver, but it is quite common to meet 
with such examples in dead-house specimens, especially when the patients 
have fallen from a height and have been killed by the accident. Its 
existence usually implies the application of greater force than results 
from a fall upon the hand upon the sidewalk. The latter represents the 
usual accident, while a fall from a height is the exceptional accident, and 
the character of the fracture is therefore exceptional. 



Fig. 95. 



Fig. 96. 



Fig. 97. 






Impacted fracture. (Au- 
thor's collection.) 



Comminuted fracture. (Au- 
thor's collection.) 



Bigelow's case of commi- 
nuted fracture of the lower 
end of the radius. 

In the accompanying woodcut (Fig. 95) is seen an impacted and com- 
minute! fracture of the lower end of the radius. Dr. James Wentw r orth, 
of Troy, N. Y., who sent me the specimen, says that the patient, a man, 
aet. 50, in a fit of delirium, jumped from a third-story w T inclow T , alighting 
upon the stone pavement. He survived the accident less than one hour. 

Fig. 96 Is from a specimen presented to me by Dr. William Van Buren, 
and was found in an autopsy at the New York City Hospital. In this 



1 Callender, St. Barth. Hosp. Rep., p. 281, 1865. 
-' Cameron, Glas. Med. Journ., March, 1878. 



COLLES'S FKACTURE. 331 

specimen there is comminution, without impaction or displacement. The 

line of separation between the upper and lower fragments is transverse, 
and the lower fragment is divided into five distinct pieces, cadi Line of 
fracture involving the joint. 

One curious example of this form of fracture is reported by Dr. Bige- 
low, of Boston (Fig. 97). The patient had fallen, and. being otherwise 
seriously injured, ultimately died in the Massachusetts General Hospital. 
At first he had only complained of lameness at the wrist, as if it had been 
severely sprained: but at the end of several days the joint became swol- 
len, and from the persistence of the swelling Dr. Bigelow was Led to 
diagnosticate a stellate crack in the articulating extremity of the radius, 
he having met with a similar case two years before, when a patient with 
the same symptoms had died of other injuries, and exhibited a crack in 
the same place, but less extensive than in this case. There was found, 
in this last example, a star-shaped fissure on the articulating surface, 
without displacement. These fissures penetrated the shaft fur an inch or 
more. Dr. Bigelow thought that the bones of the wrist acted as a wedge 
to spread the corresponding hollow of the articulating extremity, and that 
this specimen would explain the persistence of some cases of sprained 
wrist. 1 

Robert Smith has described a fracture occurring at the same point, 
and probably possessing nearly the same characters as Colles's fracture, 
in which the lower fragment is thrown forwards instead of backwards, 
and which lias generally been the result of a fall upon tin 1 back of the 
hand. There is no such specimen, however, in any of the pathological 
collections in Dublin, nor ha- Mr. Smith ever seen a specimen obtained 
from the cadaver, although he reports a case which fell under his obser- 
vation in practice. 

I have myself seen one such case, 2 but I regret to say that my exami- 
nation of the condition of the arm was nor such as to enable me to give 
a very satisfactory account of the cause and symptoms of the accident. 
Referring, however, to the experiments upon the cadaver detailed in the 
succeeding pages, it will be seen that I have been able to produce this 
fracture by forced palmar flexion of the hand. 

Fracture of the Styloid Processes Accompanying Colles's Fracture. — 
Nelaton observes that all the varieties of this fracture which he ha- seen 
are often accompanied with fracture of the styloid apophysis of the ulna. 
and with a tearing of the triangular ligament. Cameron, also, thinks 
it more common in connection with ;i Colles's fracture than has generally 
been supposed; and. in confirmation of this opinion, report- five C 
which he ha- himself observed. 8 

I believe I have seen two examples of a fracture commencing on the 
radial side of the bone and terminating in the joint, the separated frag- 
ment including considerably more than the styloid process; but neither 
of these eases has been verified by an autopsy. They were described 
in detail in the third edition of this book. 

1 Bigelow, B •• Hi I. and Surg. Journ., vol. lviii. ) 

2 Trai ix. p. 1 16. 

II. C. Cameron, ' ■!. Journ., vol. \. 



■ \--\-2 FBACTURES OF THE RADIUS. 

In my experiments upon the cadaver, hereafter to be described, the 
styloid process of the radius has been broken off twice at its base. 

Dislocation of the Lower End of 'the Ulna in Connection with Colles 's 
Fracture. — Dr. E. Moore, of Rochester, N. Y., has demonstrated, by 
examinations upon the cadaver and by experiment, that in a certain pro- 
portion of cases the internal lateral ligament, and the triangular fibro- 
cartilage give away under the force which has occasioned the fracture, 
the styloid process is thrust under or through the annular ligament 
and imprisoned: in fact, the ulna becomes dislocated, and is retained by 
the annular ligament in its new position; this dislocation being accom- 
panied in some cases with a fracture of the styloid process of the ulna. 
Nor can the reduction of the fracture of the radius be accomplished until 
the ulna is released from its imprisonment. Reduction is to be accom- 
plished by extension and partial circumduction; the hand being grasped 
firmly and extended first to the radial side, then backwards to the ulnar 
side, and finally forwards, or in the position of flexion. During the 
entire manoeuvre the wrist is held firmly by the opposite hand of the 
surgeon. The test of reduction is to be found in the presence of the head 
of the ulna on the radial side of the ulnar extensor. 

In order to retain the ulna in place when reduction is effected, Dr. 
Moore places a thick, firm compress over its lower end, on the palmar 
and ulnar margins of the forearm, and secures this in place with a broad 
band of adhesive plaster drawn firmly around the wrist. The forearm 
is then placed in a narrow sling passing under the wrist and compress. 
This completes the dressing. 1 The five examples presented by Dr. Moore 
and verified by an autopsy, must be regarded as exceptional cases; all 
of them being results of falls from a considerable height, and most of them 
had proved speedily fatal, thus affording an opportunity for post-mortem 
inspection. They are not fair representatives of that class of cases which 
are caused by falls upon the hand in the street, and which have been 
regarded as typical cases. Dr. Moore concludes, however, from autop- 
sies, and from personal observation of other cases, that "luxation of the 
ulna exists in more than half of the cases." But I was never able to pro- 
duce ir in any of my experiments upon the cadaver; that is to say, the 
extensor carpi ulnaris was never dislodged from its groove, and this is 
whal lie considers essential to the luxation. By the change of position 
of the lower fragments of the radius and ulna the extensor carpi ulnaris 
is less distinctly felt, or it cannot be felt at all, but the dissection always 
-how- thai it remains in its groove. Indeed, I feel persuaded that it 
cannol he torn from its normal position except by great force, such as 
was applied in all the cases mentioned by Dr. Moore. I shall refer to 
this matter again in connection with dislocation of the ulna. 

In the following case, although the patient fell from a considerable 
height, and the lower fragment of the broken radius was comminuted, 
there was no displacement of the ulna. John Borck, aet 62, fell, Octo- 
ber -2'K l sv <>. twenty-four feet, and was taken to St. Mary's Hospital, 
I><-troit. lie was found to have a rupture of the left gluteal artery, and 
;i fracture of the right radius. Dr. T. A. McGraw tied the gluteal ar- 

1 Moore, New York Med. Eec, April 1, 1870; March 20, 1880. 



COLLES'S FEACTUEE. 333 

tery by an external incision, but death occurred on the same day. The 
autopsy disclosed a Colles's fracture. 

•• Thi ulna was found in its place. Xo ligaments anywhere around 
the joint were broken or injured in the least, neither was there any ex- 
travasation of blood near the fracture. The lower end of the radius was 
broken into four fragments, which were, however, held together by the 
periosteum and ligaments. They were broken off the shaft just one-half 
inch from the articular surface, and were inclined back with the charac- 
teristic deformity. It was with difficulty that they could be brought into 
proper apposition, and only by first making traction, and then bending 
towards the palmar surface. It was evident that they were held in their 
acquired position by bony impaction and by nothing else. It was diffi- 
cult even when the bones were bare of flesh to get much crepitus, owing 
to the spongy consistency of the bone at that point." 1 

Barton's Fracture, as distinguished from a Colles's Fracture. — In the 
first volume of the Philadelphia Medical Examiner (1838) will be found 
a description, by J. Rhea Barton, of Philadelphia, of a form of fracture 
occurring through the lower end of the radius, which is probably much 
less common than Colles's fracture, and which had hitherto escaped the 
notice of surgeons. Its peculiarity consists in the line of fracture ex- 
tending very obliquely from the articulation, upwards and backwards, 
separating and displacing the whole or only a portion, as the ease may 
be. of the posterior margin of the articulating surface. I have not 
recognized this fracture in any instance which has come under my own 
observation, nor have I been able to find a cabinet specimen in any 
pathological collection. Dr. Barton was not able to prove the correct- 
•f his diagnosis by an autopsy, and the only well-authenticated 
example which I can find upon record is that to which Malgaigne has 
alluded, as having been seen by M. Lenoir, and of which an account 
was published in the Archives G-erUrale% de Medeeine^ in 1839. M. 
Lenoir believed it to be a simple luxation of the hand backwards, but 
the patient having died, he was able to correct his diagnosis by an 
autopsy. A considerable fragment had been broken from the posterior 
lip of the articular surface, the line of fracture being from below up- 
wards, and from before backward.-. This fragment had become displaced 
upwards and backwards, carrying with it the carpal bones, and produc- 
ing thus the appearance of a simple dislocation. 3 The possibility of such 
a fracture must be admitted, since in my experiments upon the cadaver 
by avulsion, it has several times been produced; but the infrequency of 
cabim us furnishes a presumption that it i> exceedingly rare and 

exceptional. 

M Collet I ,—A i the precise mechanism of 

this accident — speaking now only of the well-characterized Colles's frae- 
tar e — there can be very little doubt. In ;i large majority of examples 
it is the result, primarily and mainly, of two fore- acting in an op] 
direction, -•■ angle, one being the weight of the body in falling. 

and the other the unpad or resistance of the ground, the bone giving 

2 M ii. p. 700. 



334 



FRACTURES OF THE RADIUS. 



way, as is usual in other long bones, nearest the point of impact, where, 
owing i<» the unyielding nature of the resistance as compared with the 
yielding nature of the impulse (or weight of the body), the vibration is 
the greatest; and in this particular case, the fracture is not only almost 
always in the lower end of the bone, but also at or near that point where 
the bone is less strong than elsewhere, namely, where the compact tissue 
ends and the more spongy tissue commences. 

This view of its mechanism was illustrated experimentally by M. 
Nelaton. 1 Having amputated the forearm upon a cadaver, and sawn off 
the olecranon process, he placed the palm of the hand upon a solid sur- 
face, the forearm being vertical, and then struck a heavy blow upon the 
upper end of the two bones. Upon dissection he found the radius 
broken transversely, twelve to fifteen millimetres from the lower end, 
the lower fragment being tilted backwards. 

I have repeated this experiment, and with the same result. It is not 
easy, however, to produce the fracture in this way upon the cadaver, 
unless we select the bones of young persons or delicate women for the 
experiment; the force required to cause the fracture being greater than 



Fig. 98. 



Fig. 99. 





Transverse fracture of the lower end of 
radius : caused by forced palmar flexion ; in 
the cadaver. 



Transverse fracture of lower end of radius ; 
caused by forced dorsal flexion; in the 
cadaver. A. Internal lateral ligament. 
B, Third fasciculus of anterior carpal liga- 
ment. C. Anterior radio-ulnar ligament. 



is required in the living subject, because the muscles are relaxed and the 
stability of the bones is not well maintained. 

We see, then, that in addition to the two forces acting in opposite 



1 Nelaton, Chir. Path., t. i. p. 740. 



COLLES'S FRACTURE. 335 

directions, already mentioned as constituting, in most cases, the efficient 
cause of the fracture, there must be added, as extrinsic, bin important, 
muscular action, which insures the fixedness of the articulation at the 
elbow and wrist. 

In a few cases also the mechanism of the fracture will admit of an- 
other explanation. A Colles's fracture lias been caused in the living 
subject by simply forcing the hand strongly backwards, and without a 
fall or sudden impact. Thus Yoillemier, 1842, relates that he had seen 
the fracture once caused by a fall upon the lower half of the hand, in 
which the heel of the hand did not touch the ground: but another case 
was even more conclusive, the fracture being caused by forced flexion 
(probably "dorsal flexion'*') made by a comrade. According to Mal- 
gaigne. M. Bouchet was the first to observe this mode of causing the 
fracture: his observations having been made exclusively upon the 
cadaver (1834). In trying to dislocate the wrist, he found he could 
produce only a fracture of the lower end of the radius, sometimes with 
other lesions, and especially with fracture of the styloid process. 1 

In his treatise on Fractures, published in 1855, Malgaigne, while ac- 
cepting the theory of Bouchet. that is, while regarding the fracture as 
being produced by the action of two opposite forces — the weight of the 
body, and the resistance of the soil — declared that the observations of 
Bouchet and Yoillemier led him to believe that cases of fracture by ar- 
rachement (a cross-strain of the ligaments) might be more common than 
had been suppo>cd. 

In 1860-61, an important memoir by M. Ozanim Lecomte 2 appeared, 
in which that surgeon stated that it was his opinion that the fracture 
was produced solely by arrachement, and that neither muscular action 
nor shock had any part in it. This opinion was supported by Duplay, 
Anger. 3 and Tillaux. 4 the latter of whom says: " I agree with Lecomte 
in admitting that the classical fracture of the lower end of the radio- is 
always produced by an avulsion caused by the ligaments." 

According to Dr. P. S. Conner. 5 of Cincinnati, Dr. Gordon, of Bel- 
fast, in a memoir on Colles's fracture, published in 1875, maintained 
that the bony h-sion is due "to a transverse rupture of the fibres of the 
lower end of the radius, as a result of forced extension of the hand." 
Dr. Conner, who made experiments regarding the subject, Bays that they 
have demonstrated to him the correctness of thai theory. 

In May, 1878, Dr. Lewis A. Pilcher, of Brooklyn, X. Y.. ,; repeating 
the experiments of his predecessors, came to an identical conclusion, viz.. 

rnr lea lux, d Paris, July, 1834. From Malgai 

!i. and Feb. 1861. 

* Tillaux. : t. Topograj 1' 

6 Pilcher. papei S Section of the N< w Fork Acad, of lied., 

ReC., .In: 71. 

I> . Pilcher, in ; I before the Academy, made no mention of 1 1 j * - <>|iin- 

ind experimi ' don, and others. I was, th< 

led to speak of I ents, in the sixth edition of tin- treatise, ;>- n< 

wholly original. I am now convinced that they were not: and thai in so much I 

did injustice to th e Pilcher, had reful study of this 

subject by th '"4 n:i '' arrived at the same, <t nearly tin: 
same, concb - 



336 



FRACTURES OF THE RADIUS. 



thai Colles's fracture is due to an arrachement, caused by the dorsal 
flexion of the wrist. A few of Dr. Pilcher's observations deserve to be 
mentioned, on account of their importance. For example, he has no- 
ticed that if the dorsal flexion of the wrist is carried to extremes, and 
if the interior fragment is very much tilted backwards, the periosteum 
on the posterior surface of the bone, which is reinforced by a certain 
Dumber of* aponeurotic fibres, is torn or detached from the radius, thus 
allowing the inferior fragment to ascend backwards, and to be penetrated 
by the posterior border of the superior fragment. 

I >r. Pilcher has also observed that the chief cause of the peculiar posi- 
tion assumed by the hand after this fracture was the presence of " a 
strong oblique fasciculus of the anterior ligament of the wrist, which ex- 
tended from the cuneiform bone to the anterior border of the styloid 
process of the ulna. By the backward displacement of the carpus, and 
the attached radial fragment, that ligament was put upon the stretch, 
limiting all motion until relaxed." 

It will be seen that Dr. Pilcher attributes nothing of the peculiar phe- 
nomena to the integrity of the internal lateral, triangular, and radio- 
ulnar ligaments ; but to my mind it is very plain that this view of the 
subject is too exclusive, and that whenever these latter ligaments remain 
untorn they contribute to the malposition of the hand. 

I have repeated these experiments of Bouchet, Lecomte, and others, 
many times upon the cadaver ; and while they confirm in some measure 

the observations of these surgeons, I am 
far from being convinced that the classical 
fracture, occasioned by a fall upon the 
palm of the hand, is due exclusively to the 
action of the ligaments. I presented to 
the Surgical Society of New York, March 
22 and July 30, 1881, twelve specimens 
of Colles's fracture, and compared them 
with a still larger number of specimens in 
which the fracture had been produced upon 
the cadaver by forced dorsal flexion. The 
comparison showed that there was a marked 
difference between the two classes of frac- 
tures, as regards the seat and direction of 
the lesion. 1 The results of my experi- 
ments upon the cadaver may be summar- 
ized as follows : 1st. In some there is only 
a laceration of the anterior annular liga- 
ment of the wrist, which, occurring in the 
living subject, would pass for a sprain of 
the wrist. 2d. The styloid process of the 
radius may be alone broken off at its base. 
3d. The anterior lip of the radius may be 
broken off, the line of fracture being trans- 
verse, but not involving the whole thick- 
ness of the bone. 4th. The line of frac- 



Fig. 100. 




Fracture at base of styloid process 
of radius, and laceration of annular 
ligament ; caused by forced dorsal 
flexion ; in tbe cadaver. 



1 Med. Kecord, July 25 and 30, 1881 



COLLES'S FRACTURE. 387 

ture is occasionally oblique from the ulnar to the radial side of the 
radius, commencing outside of the joint and terminating in the joint. 
5th. The line of fracture is sometimes transverse, involving the entire 
thickness of the bone ; but it is usually much lower down than when it 
is caused, in the living subject, by a fall upon the hand ; and there is 
less obliquity in the line of fracture from before back, than in the latter 
case. 6th. That portion of the carpal ligament which passes obliquely 
downwards to be inserted into the styloid process of the ulna is always 
untorn, while rupture of the radio-ulnar, triangular, and internal lateral 
ligament is occasionally found. 7th. In some cases there is a mere fis- 
sure or crack of the bone, not extending through its entire thickness, 
and which could not have been recognized in the living subject. 8th. 
In others it is more or less tilted or pressed back, but not overlapped ; 
and these, constituting a majority of the whole, were easily replaced 
in their natural position by simply pressing the lower fragment for- 
wards, as has been my practice in man} 7 cases hitherto. 9th. When 
the force applied is greater or longer continued the lower fragment is 
displaced backwards upon the upper, the periosteum is torn up pos- 
teriorly : and there would be impaction, no doubt, if the muscles had 
their normal power of contraction, or if added to the cross-strain there 
had been the driving force of a fall upon the palm of the hand ; and in 
these cases it was difficult to tilt the lower fragment forwards into line 
without first relieving the strain upon this periosteal ligament by the 
method described by Pilcher. 10th. The character of the lesions in the 
opposite wrists of the same cadaver was generally symmetrical ; the same 
le>i«>n being caused by the same manipulation in one arm as in the other. 
11th. Fractures of the radius were produced by forced palmar flexion, 
but not quite so readily, and the fractures occurred a little lower than is 
usual in a Colles's fracture. 

These are the facts as observed by me in the dead-house experiments, 
and no doubt they illustrate to some extent the mechanism of this acci- 
dent as it occurs in life; but it is apparent that in some respects the 
circumstances differ. There is in the case of the cadaver no muscular 
contraction to give fixedness to the bones, and to displace the fragments 
after they are separated, or to maintain them in a position of displace- 
ment. The force of sudden impact caused by the weight of the body in 
filling is not present. In short, the fractures caused by the experiments 
wen- the result solely of the actios of the carpal ligaments upon the 
lower end- of the bones; they were fractures by avulsion or cross-strain, 
while in the examples presented in the Living subject they are usually the 
result of concussion, avulsion, and muscular action combined, of which 
causes perhaps the cross-strain is not the least efficient 

Prognosis. — ( >n<- hundred and five examples of Colles's fracture have 
furnished no cases of non-union, nor indeed do I remember ever to have 
seen the union delayed; but in u pretty large proportion of cases occur- 
ring in the practice of surgeons whose patients have been brought under 
my notice, -one- Blight or considerable deformity remains, and in most 
cases tin- joint remains more or less stiff and sensitive for some months. 
In one example, the case "1" a man whose arm was broken in Germany, 
when he was only ten years old, the fragments of the radius were driven 

22 



333 FRACTURES OF THE RADIUS. 

into each other, or overlapped one inch, and the ulna had been displaced 
downwards toward the fingers the same distance. This was examined 

twelve vears after the accident, and lie had then a very useful arm. 
Twice 1 have found the wrist and finger-joints quite stiff after a lapse of 
one year; in one case 1 have found the same conditions after two years, 
in one case after three years, and in two cases after five years. 

In cases treated by myself, where I have exercised great care in 
reducing the fragments thoroughly, and where the bandages and splints 
have not been applied too tightly, nor kept on too long, deformity to any 
considerable extent is the exception, and the stiffness is soon dissipated. 
1 say it has been the exception, not intending to claim that under my 
care considerable deformity has never resulted. 

Confining our remarks still to Colles's fracture, the deformity which 
has been observed most often, after the lapse of several months or years, 
is a projection of the lower end of the ulna inwards, a phenomenon ex- 
plained fully in the preceding pages. Rarely it is displaced backwards, 
and still more rarely forwards. In a majority of cases this is accompa- 
nied with a perceptible falling of the hand to the radial side, while in a 
few it is not. After this, in point of frequency, I have met with the 
backward inclination of the lower fragment. Robert Smith found this 
displacement almost constant in the cabinet specimens examined by him; 
and it is very probable that nearly all of the specimens examined by 
myself would present more or less of the same deviations upon the naked 
bone; but in the living examples a slight deviation would be concealed 
by the numerous tendons which cover this part of the arm, and perhaps 
by Borne permanent effusions, of which I shall speak more particularly 
presently. 

There remains for a long time, in many cases, a broad, firm, uniform 
swelling on the palmar surface of the forearm, commencing near the upper 
margin of the annular ligament and extending upwards two inches or 
more. The swelling continues much longer in old and feeble persons 
than in the young and vigorous. It is pretty generally proportioned to 
the amount of anchylosis existing at the wrist and finger-joints, and it 
disappears usually pari passu with these conditions. There can be no 
doubt licit tins phenomenon is due to effusions along the sheaths of the 
tendons, and in the areolar tissue external to the sheaths, and it is as 
often present after sprains and other severe injuries about this part, as 
in fractures. In many cases, however, its prolonged continuance and its 
firmness have led to a suspicion that the bones were displaced, a sus- 
picion which only a moderate degree of care in the examination ought 
easily to dispel. A similar effusion, but in less amount, is frequently 
seen also on the buck of the hand, below the annular ligament. When 
both exist simultaneously the appearances of deformity and of displace- 
ment are greatly increased. Here, then, we shall find a partial expla- 
nation of the anchylosis in the wrist and finger-joints, which continues 
occasionally many month-, or even years, if, indeed, it is not permanent; 
an anchylosis produced in a few instances by extension of the inflamma- 
tion to these joint-, but much more often by the inflammatory effusion 
and consequent adhesions along the thec;c and serous sheaths, through 
which the tendons all pass in their course to the hands and fingers, and 



COLLES'S FRACTURE. 339 

also by simple contraction of the articular ligaments, as a consequence 
of disuse, or. as it is usually termed, by passive contraction of these liga- 
ments. The fingers are quite as often thus anchylosed after this frac- 
ture as the wrist-joint itself: a circumstance which is wholly inexplicable 
on the doctrine that the anchylosis is due to an inflammation in the 
joints. Indeed. I have seen the fingers rigid after many months, when, 
having observed the case throughout myself, I was certain that no in- 
flammatory action had ever reached them. 

The peculiar swellings of the wrist and hand which have been de- 
scribed above, commence to show themselves very early after the receipt 
of the injury: but I have noticed, also, a swelling which is a little later 
in its accession, namely, an induration and fulness upon the back of the 
hand, which corresponds accurately to the position of the carpal bones, 
and presents an appearance as if all the carpal bones were slightly dis- 
placed backwards. This phenomenon is probably due to a swelling and 
induration of the numerous ligaments which bind together these bones 
posteriorly. It usually disappears after a few months. 

Nor is it any more difficult to show, I think, that the anchylosis of the 
wrist-joint is not often due to a malposition of its articular surfaces, as 
has frequently been asserted in the written treatises. 

The most superficial examination of the mechanism of this joint ought 
t<» satisfy us. that any moderate or even considerable malposition of the 
lower fragment after a fracture of the radius, is not sufficient in itself 
to occasion anchylosis. It is true that in the .fracture now under con- 
sideration, the direction of the articular surface of the radius is often 
changed, and that, while it was directed downwards, forwards, and to 
the ulnar side, it is now. perhaps, directed downwards, backwards, and 
to the radial side. But of what consequence is this so long as the carpal 
-. with which alone this bone is articulated, preserve their relations 
to the radius unchanged ? 

If any other evidence be demanded, it may be supplied by the expe 
rience - surgeons in examples of anchylosis without displacement, 

in examples of displacement without anchylosis, but in which the anchy- 
losis has yielded gradually to the lapse of time, while the displacement 
:ontinued. The following case is in point: James Ryan, a private 
in the 15th X. Y. Volunteers, fell from a height into a ditch during the 
battle of Fail- Oaks, Va., May 31, 1862, striking upon the palm of his 
left hand, and causing a simple fracture near the lower end of the radius, 
opanied probably with impaction. I do not know whal treatment 
was adopted, but when he came under my observation, in March, 1863, 
at the Central Park General Hospital, New Xork, I found the mo-! ex- 
traordinary deflection of the hand to the radial side which I have ever 
after this fracture. The hand could he turned, laterally in the 
direction of the radius, to a righl angle with the arm ; the motioi 
flexion and extension were nearly as perfeel a- in the opposite arm, and 

the hand \\;i- in all respects ;i~ useful >i- before the accident. 

To what J have -aid a- to the prognosis in these accidents, I ma 
permitted to add the opinion of our distinguished countryman Dr. Mott, 
oven iii a clinical lecture before hi- class in the University of New 

York. 



340 FRACTURES OF THE RADIUS. 

" Fractures of the radius within two inches of the wrist, where treated 
by the most eminent surgeons, are of very difficult management so as to 
avoid all deformity: indeed, more or less deformity may occur under 
the treatment of* the most eminent surgeons, and more or less imperfec- 
tion in the motion of the wrist or radius is very apt to follow for a longer 
or shorter time. Even when the fracture is well cured, an anterior 
prominence at the wrist, or near it, will sometimes result from swelling 
of the soft parts." 

To which the reporter, himself a surgeon in the city of New York, 
adds : 

"As the above opinion of Professor Mott coincides with my own 
observations, both in Europe and in this city, as well as with many of 
our most distinguished surgical authorities, I venture to hope that it 
may assist in removing some of the groundless and ill-merited asper- 
sions which are occasionally thrown on the members of our profession 
by the ignorant or designing." 1 

In evidence that we have not yet attained all that we could desire in 
the treatment of this fracture, I will quote farther : 

" In young subjects, fractures of the lower end of the radius are 
easily reduced, unite readily, and leave the use of the limb perfectly 
unimpaired ; but in old persons, who, as before stated, are especially 
liable to this injury, the result is often most unsatisfactory, even after 
the greatest care has been used during the treatment. It is frequently 
months before the hand is free from pain and regains its proper motions, 
and too often an unsightly, crooked, and permanently stiff wrist remains, 
to the great inconvenience and annoyance of the patient." 2 

" Union occurs in about a month, but rarely without some displace- 
ment." 3 

"In a large number of cases it is impossible to loosen the impacted 
fragments." 4 Ashhurst and Gross express similar opinions. Let me 
add that several cases treated lately under my observation, by the plaster- 
of-Paris and by Moore's method, both of which have recently been much 
employed in this country, have given no better average results than have 
been obtained by other methods. 

Of gangrene as an occasional result of this fracture, I shall speak 
presently, in connection with the subject of treatment. 

Treatment. — The peculiar character of the displacement which char- 
acterizes Colles's fracture, and the constant difficulty experienced by 
surgeons in obviating deformity, have led to much speculation and in- 
genious invention; and modern surgeons, especially, have thought it 
necessary to introduce here an essential modification of the usual apparel 
for broken forearms. This modification consists in employing a pistol- 
shaped splint, instead of a straight splint, by means of which the hand 
may be thrown more or less strongly to the ulnar side. 

1 Boston Med. and Burg. Journal, vol. xxv. p. 289. 

2 Holmes's System of Surgery, Amer. ed., 1870, vol. ii. p. 798. 
'■■■ Gant'fl System of Surgery, 'London, 1871, p. 463. 

4 Bryant V Surgery, London, 1872, p. 937. See also opinion of Callender on same 



COLLEs's FRACTURE. 341 

Heister 1 speaks of inclining the hand toward the ulna, while reducing 
a fracture of the radius, but when the reduction has been effected he 
recommends a straight splint. 

Among the first to advocate the permanent confinement of the hand 
in this position, were Mr. Cline, 2 and Dupnvtren. 3 Mr. Cline, and after 
him Bransby Cooper. 4 and Mr. South."' recommend the ordinary straight 
splints for the forearm, but the rollers by which the splints are secured 
in place are not permitted to extend lower than the wrist ; so that when 
the forearm is suspended in a sling, in a state of semi-pronation, the 
hand shall fill by its own weight to the ulnar side. 

Dupuytren, and after him Chelius. adopt, in addition to the palmar 
and dorsal splints, the "attelle cubitale," or ulnar splint: which is a 
gutter, composed of steel, iron, tin, or some other metal, and made to 
fit the ulnar margin of the forearm and hand, when the hand is drawn 
forcibly to the ulnar side. Blandin, 6 Nelaton, 7 and Goyraud, s also, under 
certain contingencies employ the same. 

Most surgeons, however, employ either a palmar or a dorsal splint; or 
both palmar and dorsal splints constructed with a knee, or pistol-shaped, 

Fig. 101. 



X-'latorTs splint for fracture of the radius. 

and they thus avoid the necessity of the ulnar splint. Thus, NeMaton, 9 
Robert Smith. 1 " and Erichsen." recommend tlii< peculiar form only in the 
dorsal Bplint; while Bond, 12 Hays, 13 E. P. Smith.' 1 (;. F. Shrady," and 
other-, especially among the Americans, place the pistol— Imped splint 
st the palmar surface of the forearm and hand. 

1 De Lavrentii Heisteri, [nstitutiones Chirurgicae, para prima, p. 208, Amsterdam 
ed., 1739. 

- M . _ _ torn. i. p. 614, Pai 

3 Dupuyl '• Ion ed., i L40- 

• i;. i 9 2 2 \ merican ed, 

( j'g 8 i.. vol. i. ]». 61 

6 Malgaigne, op. cil . torn. i. 

" >' ( ;; th. Cnir., torn, i. p. 7 \: . 

8 Ibid., p. 3 v • . ; . • , p. 717. 

10 R. Smith, op. cit, } ichsen, Surgery, p. 216. 

« Bond, A:; • ■ Jo • Lpril, 1862. [bid., -Ian. Lg 

M E. I'. Smith, Buffal 226. 



:\\-2 



K i: ACTUKES OF THE RADIUS. 



A low modern Burgeons have not seen fit to adopt this peculiar prin- 
ciple o\' treatment, or this form of dressing under any of its modifica- 
tions. Colles 1 recommends a straight palmar and dorsal splint, and 
does not incline the hand. Barton 2 advises the same, and Skey, having 

Fig. 102. 




Bond's splint. 

declared his preference for a couple of broad, straight splints, adds : 
iw Great care should be taken to prevent the hand falling, and this object 
will be attained by inclosing the entire forearm and hand in a well- 
applied sling." 3 

Fig. 103. 




Hay's splint. 

Stephen Smith employs two broad, straight palmar and dorsal splints, 
secured in position by adhesive strips, the hand being thrown to the 
ulnar side by reversed turns of adhesive plaster. 

Fig. 104. 




E. 1\ Smith's splint. Surface applied to forearm. A. Forearm piece, made of felt, with 
incurvated margins. 

Professor Fauger, of Copenhagen, has undertaken to treat this fracture 
in --in.' sense without any splint, the forearm and hand being simply 
laid over a double inclined plane, so as to bring the wrist into a state of 



1 ( 'olios, Lectures on Surgery, p. 325. 
3 Skey, Operative Surgery, p. 161. 



2 Barton, Phil. Med. Exam., 1838. 



COLLES S FRACTURE. 



343 



forced flexion. " The hand having been brought into a position of strong 
flexion, the forearm is placed, pronated. on an oblique plane, with the 
carpus highest, the hand being permitted to hang freely down the per- 
pendicular end of the plane." 1 M. Velpeau, in a report of his surgical 
clinic at La Charite for the year ending September. 1846, says this plan 
has been tried during the year, and " the result has not been very satis- 
factory. The experiment, however, has not been decisive upon this mode 
of treatment." 2 

Fig. 105. 





E. P. Smith's splint. B. Opposite surface. D, the band-block, is connected with the 
forearm piece by two circular brass plates, which move upon each other, in order that the 
hand-block may assume any desired angle with the arm. In this way it may be adapted to 
either the right or left arm. It is fixed by a nut, seen on the brass plate. The letters C C 
indicate the extent of motion allowed to the hand-block. 

The late Henry S. Hewit, of this city, devised a very ingenious splint, 
by which the mobility of the wrist and fingers might be more perfectly 
retained, and the wrist put into any desirable position. The following 
is the description given by himself of the apparatus : " The wooden 
ball grasped by the hand is connected by a rod to a slender bar running 

Fig. 106. 




■&— ■- 



longitudinally upon the face of the splint, and capable of being flexed at 
any desirable length. The rod is attached to the travelling connection 
by a universal joint, giving play u, the ball in limited movements of 
flexion, extension, pronation, and supination. Tlif natural tendency is 
for the patient to make these movements, and perpetually to relax and 

I . • . • m 
B ■■ . p. 218. 



344 FRACTURES OF THE RADIUS. 

contract the fingers. The splint upon the inner surface of the arm is 
antagonized by a plain flat-splint on the outer surface, extending to the 
superior border of the wrist-joint. This splint has been used for upwards 
of two years by myself and others, particularly by Dr. W. T. "White, at 
the Demill Dispensary, and has given good results." 1 

We come now to consider how far this peculiar treatment, ulnar incli- 
nation, is capable of answering the special indications of the case we are 
studying. 

It is assumed, as I have already intimated, that by bearing the hand 
Btrongly to the ulnar side, the fragments of the radius are brought more 
exactly into apposition, and more easily and effectually retained ; an 
assumption which supposes two things to have been determined : first, 
that there exists an overlapping of the fragments, either through the 
whole extent of their broken surfaces or especially toward the radial side, 
or that the upper end of the lower fragment is inclined to fall against 
the ulna, or that all of these several conditions coexist; and, secondly, 
that if such displacements do exist, they can be remedied by this 
manoeuvre. 

The first of these suppositions seems to have been sufficiently con- 
sidered by all those gentlemen who have particularly examined the 
specimens contained in the various pathological collections, and to whose 
careful investigations I have already frequently adverted. With rare 
exceptions, none of these displacements have been found to exist, 
although, as has been observed, a casual inspection of the arm when 
recently broken would often lead to an opposite conclusion. I do not 
here speak of impaction, which is usually upon the posterior margin, if 
it exists at all. 

In regard to the second supposition, namely, that, where such dis- 
placements do exist, a forced adduction will aid in the retention of the 
fragments, I shall have to speak more cautiously, because, so far as I 
know, my opinions have received as yet no public and authoritative 
indorsement. In order that adduction may prove effective, there must 
be some point upon which to act as a fulcrum. It is of no use that we 
rotate the hand for the purpose of making extension unless there can be 
found a resistance or fulcrum upon which the rotary motion may be 
performed. Such a fulcrum exists, no doubt, but to determine its availa- 
bility we must ascertain its character and position. 

It is not in the lower end of the ulna, for the ulna has no point of 
contact with the carpal bones, and when, in the natural state of these 
parts, the hand is inclined to the ulnar side, the lower end of the ulna 
rides freely downwards upon the wrist until arrested by the ligaments 
which unite it with the carpus, or by the capacity of the joint to admit 
of motion in this direction. When the lower end of the radius is broken, 
and the ligaments of the joint are more or less torn, the ulna, although 
thrust downwards much farther, perhaps, than it could ever descend in 
its Dormal Btate, still fails to find a support, and, spreading wider and 
wider from the radius as it is thrust further upon the hand, no limit 
can l»e given to its progress in this direction. It was thus that, in one 

1 Hewit, Medical Record, April 1, 1873. 



COLLES'S FRACTURE. 345 

example already mentioned, I found the ulna carried downwards one 
inch or more, and this was the fact in several cases reported by Moore, 
and verified by the autopsy. 

The resistance will, then, in nearly all cases, he found to be in those 
ligaments which bind the lower fragment to the lower end of the ulna. 
and the ulna to the carpal bones, viz.. the radioulnar, the triangular, 
and the internal lateral ligaments, which in the normal state of the parrs 
constitute the centre upon which forced adduction expends its power, and 
which still continue to be the point of resistance when the radius is 
broken. But how feeble and uncertain must be a resistance which 
depends solely on these injured and often lacerated ligaments! And 
how painful to the patient must be an extension sufficient to overcome 
the action of nearly all the muscles of the wrist, which is borne entirely 
by a few torn and inflamed fibres ! Even in health this position, when 
f»rced. cannot be endured beyond a few seconds, and it must be difficult 
to estimate the sufferings which the same position must occasion when 
the ligaments are torn and inflamed. 

I am not to be told that surgeons have not intended to advocate this 
extreme practice: that they have never recommended forced adduction, 
but only a moderate and easy lateral inclination, such as can be com- 
fortably borne. If they have not, then they should not have spoken of 
making extension by this means. An easy lateral inclination has no 
power to do good so far as extension is concerned, than it has power to 
do harm. But the fact is, while a majority of surgeons have no doubt 
aged less force than was hurtful, some have used more than was useful or 
Bafe; indeed, the sharpness of the curve given to the splints figured and 
recommended by Dupuytren, Nelaton, and others, sufficiently indicates 
that their distinguished inventors intended to accomplish by these means 
a forced and violent adduction. 

Malgaigne, -peaking of other means of extension applied to the fore- 
arm, suggested by Godin, Diday, andVelpeau, intended to operate only 
in a straight lino, and alluding especially to the modes devised byHuguier 
and Velpeau, remarks : "Without discussing here the comparative value 
of the two form- of apparatus, I believe that they could scarcely bo 
endured by the patients; and M. Diday tells us that, in the trials which 
h<- has made, the pain produced by the extension was bo great that he 
was compelled to renounce it. " Which observations cannot but apply 
equally to this plan of extension by adduction or to any other which 
might be adopted. I>r. G. S. Porter, of Lonaconing, Maryland, has 
used for the purpose of extension a padded wire-splint applied to the 
dorsal surface of the arm and hand, and in which the extension is sup- 
posed to be effected by adhesive plaster strips. 1 Notwithstanding the 
testimony which the experience of this gentleman has furnished of the 
value of this method, and not doubting thai ho obtained satisfactory 
results, T must be permitted to say that probably they woo due to the 
thoroughness with which he reduced the fracture in the first place, 
rather than to the efficiency of the apparatus; and I will take this 
opportunity of saying that the success claimed bj Drs. Moore and Pilcher 
for their peculiar modes of treatment, neither of whom employs splints, 



FRACTURES OF THE RADIUS. 

s, in my opinion, wholly upon the fact that they have had the 
gment and -kill to reduce the fragments effectually in the first 

fter which, as I have already said, there is usually very little 
•ility that they will - ed. In cases which have been 

•1 under my observal 3 given no better results 

than have other methods : indeed, I have not thought the success equal 
to that obtained by my own. ami some other modes of dressing, for 
which, however, mm claimed. 

After all. it must not be inferred that I have concluded to reject this 
38 Dg — the pistol-shaped splint — in all of its modifications : 
.though I am far from being persuaded of its utility as a means of 
and retention in any case, yet I am not prepared to deny to 
ae very considerable value in another point of view: and when 
judiciously employe! it can certainly do no harm. It is. I repeat, for 
another reas _vther than the one heretofore assigned, that I would 

recommend its continuance, a reason which I cannot so well explain, or 
nder intelligible, except to the practical surgeon. This posi- 
tion throws the whole lower end of both radius and ulna outwards 
1 the radial margin of the splints, and by keeping the radius more 
etely in view, it enables the surgeon better to judge of the ac- 
F the reduction, and to recognize inore readily the condition 
and situation of the con. sses. tc. This alone I have always con- 
sul! ground for retaining the angular splint: although I 
have treated a great number of arms satisfactorily with the straight 
splints aloDe. 

Finally, while - geons have been seeking to meet an indication, the 
existence of which is at least rendered doubtful, and by means which 
appear to me totally inadequate, if it did exist, they have probably 

led indifferently an indication which is almost 
uniformly present, namely, to press 1 ghly rwards the tilted frag- 

men: applied upon the wrist from behind, and to retain it in 

sses. Aii'l I cannot help thinking, that, if they 
had regarded this as the sole indication in most cases, an indication gen- 
erally so easily met. they would have made fewer crooked arms, and have 
. their patients much suffering and themselves much trouble. In 
I - this opinion, I must be permitted to say again that in my own 
tice deformity after this fracture is the exception. I never apprehend 
38 ti - comminution, or other serious complica- 

In other, and somewhat see where the lower fragment is 

driven back until its brok< suri s tl broken surface of the 

in addition to the consequent impaction there is 

- xibed by Richer, we must first. 

y him. increase the dorsal tiexi> . - -lie finger against the 

proximal end of the low, _ -. and then, while making 

from the hand, g _ the hand and the lower fragment forwards. 

- if. by the method of direct and forcible pressure 

fn»m behind, or by Pitcher's mollification of this method. Ave have once 

_ ' _ ghly into place, it will remain in place 

with little or no retentive apparatus; unl< - '.. the Lover fragment 



COLLES'S FRACTURE. 347 

be comminuted. In which case some degree of deformity will ensue 
whatever plan of treatment we may adopt. 

In case the ulna is dislocated also, and is imprisoned by the annular 
ligament, circumduction with extension, as practised by Dr. Moore, and 
heretofore described, will be required. 

It only remains for us to determine the precise form of splint which 
ought to be preferred, and to describe its mode of application. 

The narrow "attelle cubitale" of Dupuytren is inconvenient; nor 
can I give the preference to the curved dorsal splint recommended by 
Nelaton, and employed by Robert Smith. Erichsen, and other-. It is 
not to me a matter of entire indifference, in case only one curved splint 
is employed, whether this be applied to the palmar or dorsal surface of 
the forearm. Foreign surgeons, so far as I know, have applied this 
splint to the dorsal surface, and the straight splint to the palmar: while 
American surgeons have adopted almost as uniformly the opposite rule — 
to whose practice, in this respect. I acknowledge myself also partial. It 
is t<> the curved splint rather than to the straight that we mainly trust : 
not simply, or at all. perhaps, because of its form, but because the 
curved splint is also the long splint. This is the splint, therefore, which 
ought to be the most steady and immovable in it- position. Xow. the 
very irregularities of surface upon the palmar aspect of the forearm and 
hand, instead of constituting an embarrassment, enable us. when the 
splint is suitably prepared and adjusted, to fix it more securely. More- 
over, upon it alone, after a few days, the surgeon may sec fit to rely. 
and in that case it ought to be applied to that surface of the arm which 

ilerant of continued pressure. The palmar surface, as I 
more muscular, and as having been more accustomed to friction and to 
sure, must necessarily have the advantage in tin- respect. The 
palmar splint terminating also at the metacarpo-phalangea] articulations. 
: 1 of at the wrist, as the -hort straight splint must do when the 
hand is adducted. enables the hand to be flexed upon it> extremity over 
a hand-block, or pad of prop. Such are the not insignificant 

advantages which we claim for this mode over that pursued by our trans- 
atlantic brethren. 

The block, suggested first by Bond, of Philadelphia, is a valuable 
addition, since tie- flexed more easy for the fb g 

and in case of anchylosis this position renders the whole hand more 
useful. 

Levis employs a Bplint made of copper, lined with tin. and furnished 
with f little pointed i along the edges to prevent the 

bandag< 

No doubt this Bplint would answer its purpose well in case it fitted 
accurately: but to insure this the surgeon must be supplied with a con- 
siderable number, differing materially in length, breadth, and form; or 
it must be made for the patient who is under treatment. I have occa- 
Uy employed a splint of this form; <>u<>- when I had broken my 
own wrisl — ' !tur< — and with admirable results ; hut I have 

always osed for this pur] thick sheet of gntta percha, which 



us 



FRACTURES OF THE RADIUS. 



in a few minutes can be fitted with the most absolute accuracy. Gum- 
shellac cloth ran be adapted, after thorough soaking in boiling hot 
water, with Dearly the same degree of accuracy, and I think sole-leather 
might also, but in the latter ease, after being moulded it would have to 
be laid aside to dry and harden. The only argument upon which this 




metallic splint. 



distinguished surgeon can, therefore, justify the use of a fixed form of 
metallic splint, must be the need of a proper model for the instruction 
<>f inexperienced surgeons. 

In most cases I prepare extemporaneously a splint from a wooden 
Bhingle, which I first cut into the requisite shape and length; the length 
being obtained by measuring from the front of the elbow-joint, when the 
arm is Hexed to a right angle, to the metacarpophalangeal articulations, 
the fingers being first Hexed. It ought, indeed, to fall half an inch short 
of the bend of the elbow, to render it certain that it shall make no un- 
comfortable pressure at this point; ami the direction to measure with 
the arm flexed i- of sufficient importance to warrant a repetition. The 
breadth of the splint should be in all its extent just equal to the breadth 
of the forearm in its widest part, except where it is to receive the ball of 
the thumb, so that there shall he in, lateral pressure upon the bones. If 
the splint is of onequal breadth, the roller cannot be so neatly applied, 
and it is more likely to become disarranged. Thus constructed, it is to 



Pig. ins. 



Fig. 109. 




I 



Author*! palmar splint : righl ar 



Author's dorsal splint; frequently omitted. 



he covered with ;i -nek of cotton-cloth, made to fit moderately tight, with 
the seam along it- back, and afterwards stuffed with cotton-batting or 
with curled hair. The.,, materials may he pushed in, and easily ad- 



COLLES S FRACTURE. 



349 



justed, wherever they are most needed, from the open extremities of the 
sack. While preparing, the splint must be occasionally applied to the 
arm until it fits accurately every part of the forearm and hand, only that 
the stuffing must be more firm a little above the lower end of the upper 
fragment, and in the hollow of the hand. Between these two points 
there should be little or no cotton. The open ends of the sack are then to 
be neatly stitched over the ends of the splint, after which the splint may be 
laid directly upon the skin without any intermediate compresses or rollers. 

The advantages of this form of splint are easily comprehended. They 
consist in facility and cheapness of construction, accuracy of adaptation, 
neatness, permanency, and fitness to the ends proposed. There is also 
no possibility of making painful or injurious pressure upon the arteries 
or nerves which lie upon the front of the wrist. 

The extemporaneous splint recommended by Dr. Isaac Hays, of Phil- 
adelphia, is very similar, but it lacks the neatness and permanency of 
that which I have now described. 

In most cases it is better to employ, also, at least during the first fort- 
night, a straight dorsal splint, of the same breadth as the palmar splint, 
and of sufficient length to extend from the elbow to the middle of the 
carpus. This should be covered and stuffed in the same manner as the 
palmar splint, except that here the 
thickest and firmest part of the 
splint must be opposite the carpus 
and the lower fragment. 

Having restored the fragment to 
place by some one of the methods 
already described, the arm is to be 
flexed upon the body, and placed 
in a position of semi-pronation ; 
when the splints are to be applied, 
and secured with a sufficient num- 
ber of turns of the roller, taking 
especial care not to include the 
thumb, the forcible confinement of 
which is always painful and never 
useful. 

Let me repeat that, in most 
3, all of our success will de- 
pend not BO much upon the par- 
ticular form of apparatus employed 
as upon whether we have properly 
reduced the fracture in the early 

_•■ of the accident. When once 
reduced it is, with rare exceptions, 
easily kept in place. 

I cannot too severely reprobate 
the practice of violent extension of 
the wrist in the efforts fit reduc- 
tion, when no overlapping or impaction of the fragments exists and 
the ulna is not dislocated; and that, whether this extension be applied in 




The author's dressing complete. The curved 
palmar splint is not in view, only the dorsal. 
The faint white lines represent the roller. The 
sling is omitted, for the purpose of bringing 
the other dressings into view. 



850 l'l: AC 11' B ES OF Til E RADIUS. 

a Btraight line, or with the hand adducted. It has been shown that in a 
great majority of cases do indication in this direction is to be accom- 
plished : and to pull violently, under these circumstances, upon the wrist, 
i- not only useless, bul hurtful. It is adding to the fracture, and to the 
other Injuries already received, the graver pathological lesion of a stretch- 
ing, a >piain of all the ligaments connected with the joint. I am per- 
suaded that to this violence, added to the unequal and too firm pressure 
of the splints, aro. in a greal measure, to be attributed the subsequent 
inflammation and anchylosis in very many cases. 

The first application of the bandages ought to be only moderately 
tight, and as the application and swelling develop in these structures 
with rapidity, the bandages should he attentively watched, and loosened 
as soon a- they become painful. It must be constantly borne in mind 
that, to prevent and control inflammation, in this fracture, is the most 
difficult and by far the most important object to be accomplished, while 
t<« retain the fragments in place, when once reduced, is comparatively 
easy. 

During the first -even or ten days, therefore, these cases demand the 
most assiduous attention: and we had much better dispense with the 
Bplints entirely, as advised by Fauger, than to retain them at the risk of 
increasing the inflammatory action. Indeed, I have no doubt that very 
many cases would come to a successful termination without splints, if 
only the hand and arm were kept perfectly still in a suitable position 
until bony union was effected. 

I must also enter my protest against many or all of those carved 
Bplints which are manufactured, hawked about the country, and sold by 
mechanic-, who are not Burgeons; with a fossa for each styloid process, 
a rid-- to press between the bones, ami various other curious provisions 
for supposed necessities, but which never find in any arm their exact 
counterparts, and only deceive the inexperienced surgeon into neglect of 
the proper means for making a suitable adaptation. They are the 
fruitful sources of excoriation-, ulcerations, inflammations, and deform- 
In reference to the treatment of these fractures, the following cases 
and the accompanying remarks, by that great surgeon, Dupuytren, are 
too pertinent not to merit a place in every treatise of this character. 

" The two succeeding cases are not only interesting as fractures of 

the radius, but they are farther deserving of attentive consideration, on 

int of the serious complications which accompanied them, and which 

were the consequem retting an important precept. More than 

once, indeed, it has occurred thai the Burgeons have been so intent on 

preserving fractures in their proper position that the extreme constric- 

employed has actually caused destruction of the soft parts. Apiece 

Ivice which I have very frequently given, and which I cannot too 

- to avoid tightening too much the apparatus for fractures 

during the first few days of its being worn; for the swelling which 

Bupei mpanied by considerable pain, and may be foh 

Ir cannot, therefore, he too urgently impressed on 

young practitioners, to pay attention to the complaints which patients 

make; and to visit them twice daily, and relax the bandages and straps 



FRACTUKES OF THE RADIUS. 351 

as need may be. in order to obviate the frightful consequences which 
may spring from not heeding this necessary precaution ; by carefully 
attending to this point I have been saved the painful alternative of 
ever having to sacrifice a limb for complications which its neglect may 
entail. 

" Antoine Rilard, an. 11. fractured his right radius while going down 
into a cellar, in February. 1828, and went at once to THopital la 
Charite. When the fracture was reduced (it was near the base of the 
bone) an apparatus was applied, but fastened too tightly ; and, notwith- 
standing the great swelling and the acute pain which the patient en- 
dured, it was not removed until the fourth day, when the hand was cold 
and (edematous, and the forearm red, painful, and covered with vesica- 
tions. Leeehes, poultices, and fomentations were applied, and followed 
by some alleviation of the local symptoms, though there was much con- 
stitutional disturbance. At the close of a fortnight from the accident, 
the palmar surface of the forearm presented a point where fluctuation 
was supposed to exist ; but when a bistoury was plunged into it no 
matter followed. Portions of the flexor muscles subsequently sloughed, 
and the skin subsequently mortified. The only resource was amputa- 
tion, which was performed above the elbow six weeks after his admission; 
and he afterwards recovered without the occurrence of any further unto- 
ward symptoms. 

"R.. at. 36. was at work boring an artesian well in 1832, when he 
was -truck by part of the machinery on the right arm; he was instantly 
knocked down and thrown violently on the right thigh. A surgeon who 
was -cut for detected a fracture of the radius, and applied the usual 
apparatus, consisting of pads and splints, confined by a roller extending 
from the extremities of the fingers to the elbow, which compressed the 
arm so tightly as to give rise to very great suffering. The fingers, hand, 
and forearm were numbed almost to insensibility, and yet the surgeon in 
attendance did not think proper to loosen the apparatus. Such was the 
condition of the patient until he came to the Hotel Dieu, four days after 
the accident: the fingers were then black, cold and insensible, and 
when 1 removed the splints I found the hand likewise black, especially 
on its palmar surface. The lower part of the forearm was a shade less 
livid, but equally cold and insensible: and several vesicles filled with 
pink-colored serum were apparent on both its surfaces where the splints 
had pressed; the upper part of the forearm was inflamed, swollen, and 
painful. lie was bled, and Leeches were applied to the inflamed 
part of the arm; camphorated spirit was applied to the fingers. 

••On the following day heal was restored as low as the wrist, but the 
hand remained for the most part livid and cold, and the radial artery 
did not pi; renty leeches were applied to the forearm, and the 

local applic - continued." On the second day after admission 

thirty more leeches were applied. On the fourth day the band looked 
a little betl _ some hope of* its being saved; bur 

this was again blighted on the sixth day, by the entire loss of heal and 
ility in the part, and increased pain and swelling in the forearm, to 
which the gangrene subsequently extended. On the twelfth day ampu- 
tation was performed at the elbow-joint; but the patient did not survive 



352 FRACTURES OF THE RADIUS. 

the operation more than ten days, the immediate cause of death being 
acute pleurisy. There was a considerable quantity of purulent serosity 
on the right Bide of the chest; and abscesses were found in the lungs 
and liver. On examining the arm, there was found to be a simple frac- 
ture of the radius about its centre. 

"The above case presents a painful illustration of the neglect to which 
I have alluded. In nearly every instance the swelling of the limb re- 
quires thai careful attention should be paid to the bandage or straps by 
which the apparatus is confined. Similar accidents are likely to result 
from the employment of an immovable apparatus, of which an example 
occurred in the practice of M. Thierry, one of my pupils. He was 
summoned to visit a young girl, on whom such an apparatus had been 
applied for supposed fracture of the radius. After suffering excruciating 
ton u cut. the forearm mortified, and amputation was the only resource; 
on examining the limb, no trace of fracture could be discovered. Had a 
simple apparatus been here employed, and properly watched, the pa- 
tient's limb would not have been sacrificed." 1 

Robert Smith mentions, also, the case of a boy, set. 18, who had a 
fracture of the lower extremity of the radius, through the line of the 
junction of the epiphysis with the diaphysis, caused by being thrown 
from a horse. A surgeon applied, within an hour, a narrow roller 
tightly around the wrist. On the following day the limb was intensely 
painful, cold and discolored; still the roller was not removed, nor even 
slackened. On the fourth day he was admitted into the Richmond Hos- 
pital, when the gangrene had reached the forearm. Spontaneous separa- 
tion of the soft parts finally occurred, and the bones were sawn through 
twenty-four days after the fracture was produced, from which time 
"everything proceeded favorably." 2 

Nov. 21, 1851, a boy, ten years old, living in the town of Andover, 
Mass,, had his left hand drawn into the picker of a woollen mill, pro- 
ducing several severe wounds of the hand and a fracture of the radius 
Dear its middle. One of the wounds was situated directly over the point 
of fracture, hut whether it communicated with the bone or not was not 
ascertained. A surgeon was called, who closed the wounds, covered the 
forearm with a bandage from the hand to above the elbow, and applied 
compresses and <]>lints. The lad made no complaint, his appetite re- 
maining good, and his sleep continuing undisturbed, until the third day, 
when he began to speak of a pain in his shoulder; on the same day also 
it was noticed thai hi- hand was rather insensible to the prick of a pin. 
Early on the morning of the fourth day his surgeon, being summoned, 
found him suffering more pain and quite restless; and on removing the 
dressings, the arm was discovered to be insensible and actually mortified 
from the shoulder downwards. 

Opiates and cordials were immediately given to sustain the patient, 
and fomentations ordered. 

On the sixth day a line of demarcation commenced across the shoul- 
der, and on the twenty-firsl day the father himself removed the arm 

Dupuytren, [njuriee and Diseases of Bones, Syd. ed., London, 1847, pp. 145-7. 
EL smith, Treatise on Fractures, etc., Dublin, 1854, p. 170. 



FRACTURES OF THE RADIUS. 353 

from the body by merely separating the dead tissues with a feather. 
Subsequently a surgeon found the head of the humerus remaining in the 
socket, and removed it, the epiphysis having become separated from the 
diaphysis. The boy now rapidly got well. 

In the year 1853 this case became the subject of a legal investigation, 
in the course of which Dr. Pilsbury, of Lowell, Mass., declared that in 
his opinion this unfortunate result had been caused by too tight bandag- 
ing, and by neglecting to examine the arm during four days. 

On the other hand, Drs. Hayward, Bigelow, Townsend, and Ains- 
worth, of Boston, with Kimball, of LoAvell, Drs. Loring and Pierce, of 
Salem, believed that the death of the limb was due to some injury done 
to the artery near the shoulder-joint ; and in no other way could they 
explain the total absence of pain during the first two days; nor could 
they regard this condition as consistent with the supposition that the 
bandage occasioned the death of the limb. 1 

I cannot but think, however, that these gentlemen were mistaken, and 
that the gangrene was alone due to the bandages. In a similar case 
which came under my own observation, and in which both the radius 
and ulna were broken, the roller extended no higher than just above the 
elbow, and the patient complained of no pain until the bandages were 
unloosed, yet the arm separated at the shoulder-joint. I shall refer again 
to this example in the chapter on Fractures of the Radius and Ulna ; and 
shall take occasion then also to speak more fully of the causes of these 
terrible accidents. 

Xorris mentions another case of compound fracture of the lower end 
of the radius which came under his notice at the Pennsylvania Hospital 
in August, 1837, the arm having been dressed by a surgeon within half 
an hour after the accident, with bandages and splints. When these 
bandages were removed at the hospital, on the fifth day, u the soft parts 
around the fracture were found to have sloughed, an abscess extended 
ui) to the elbow-joint, and sloughs existed over the condyle. Severe con- 
stitutional symptoms arose, making amputation of the arm necessary." 2 

A lady, aet. 50. was also seen by Thierry, who, having broken the 
radius near its lower end, lost her fingers by the sloughing consequent 
upon a tight bandage. 3 

A woman was admitted into one of Dr. Wood's wards in the Bellevue 
Hospital about the 1st of February, 1863, who had fallen upon her hand 
a few <lays before and broken the radius just above the wrist. Her arm 
was dressed with -plinTs and bandages at one of the dispensaries in this 
city. Gangrene ensued, and when I saw her on the 8th of February, 
tin- death bad extended to the middle of the forearm, the dead tissues 
being dry and black. Dr. Wood amputated the arm, but she died. 

The remarks which have now been made in relation to the treatment 
of Colles's fracture are applicable, with only such slight modifications 
a- would naturally be suggested, to fractures of the lower end of the 
radius commencing upon the radial side of the hone and extending ob- 
liquely downward into the joint (perhaps, indeed, this ought to be 

1 Bost Med, and Surg. Journ., vol. xiviii. p. 281. 

2 Xorri-. note to Liston'e Surgery, p. 54. 

r. Journ. Mod. Sci., vol. xw. ]». 461, from [/Experience for 1838, 

23 



85 I i TU i: KS OF THE KA DIUS. 

regarded aa a variety of Colles's fracture); and it is to this form of 
fracture, especially, thai the pistol-shaped splint must be found applicable. 
[f the fracture actually extends into the joint, it must not be forgotten 
that, in order to the prevention of anchylosis, the wrist should be early 
subjected to passive motion. 

The following example of a compound comminuted fracture of the 
radius may serve to illustrate the value of a somewhat novel mode of 
treatment under certain circumstances: 

William Croak, of Buffalo, set. 30. January 29, 1856, a large piece of 
iron casting fell upon Iris arm, crushing and lacerating the wrist, and 
comminuting the lower part of the radius; he was immediately taken to 
the Hospital of the Sisters of Charity. I found the whole of the soft 
part- torn away in front of the joint, and the fragments of the radius 
projected into the flesh in every direction. The hope of saving the hand 
seemed to be scarcely sufficient to warrant the attempt; at least by the 
ordinary mode of procedure. I, however, stated to the gentlemen pre- 
sent, among whom were Dr. Rochester, my colleague, and the house sur- 
. Dr. Lemon, that I believed it could be saved if, having removed 
the fragments of the radius, we practised resection of the lower end of 
the ulna, and allowed the muscles to become completely relaxed. Ac- 
cordingly, after placing my patient under the influence of chloroform, I 
enlarged the wounds so as to enable me to remove six or seven fragments 
of the radius, leaving others which were broken off but not much dis- 
placed. I then removed with the saw T one inch and a half of the lower 
end of the ulna. The hand was immediately drawn up by the contrac- 
tion of the remaining muscles, but their tension was completely relieved. 

The wounds were closed and dressed lightly, and the whole limb was 
placed on a broad and well-padded splint covered with oiled cloth. The 
hand, which was very pale and exsanguine, w r as covered with warm 
cotton batting. 

The subsequent treatment was changed from time to time to suit the 
indications; but his recovery was rapid and complete, nor was there at 
any time excessive inflammation in any part of the limb. 

I have seen this man frequently since he left the hospital, and while 
he has recovered only a little motion in the wrist-joint, his hand and 
fingers are nearly as useful as before the accident. He is able to per- 
forin ;ill ordinary kinds of labor with almost as much ease as most other 
men; and. what is always gratifying to the humane surgeon, he does 
not fail to appreciate fully the service which has been conferred upon 
him by the preservation of his somewhat mutilated hand. 

I have recently adopted the same treatment with equal success in a 
case of gunshot wound of the lower end of the radius. 

Fractun of the Styloid Process of the Radius Independently of a 
Collet's Fracture. — I have elsewhere in the preceding pages (p. 331) 
Bpoken of this accident in connection with a Colles's fracture, and I 
wish dow to refer briefly to its occurrence independently of a Colles's 
fracture 

Dr. Butler, Bouse Surgeon to the Brooklyn Hospital, reports a case 
treated by Dr. J. C. Hutchison of Fracture of the right radius at the 
junction of the middle and lower thirds, accompanied with a fracture 



FRACTURE* OF THE RADIUS. 



355 . 



Fig. 111. 



also of the styloid apophysis in the same bone. The accident occurred 
in a lad fourteen years old. who had fallen from a height of thirty feet 
upon the pavement. The lower fracture commenced at the base of the 
styloid process of the ratlins, and extended down obliquely into the 
wrist-joint, breaking off about one-fifth of the articular surface. The 
process was drawn up on the posterior surface of the radius, about one 
inch and a half, by the supinator radii longus muscle. It was movable, 
but. in consequence of the contusion and swelling, could not be returned 
to its place. The hand occupied the same position that it does in Colles's 
fracture. 

On the eighth day an attempt was made to force down the process 
with a compress secured by adhesive plaster straps; but it could not 
be done. The hand and arm were confined also to a pistol-shaped 
splint: ulcerations ensued from the pressure of the compress, and the 
process was laid bare, but it finally became united in its 
abnormal position : the motions of the wrist, however, were 
not impaired, and the power of pronation and supination 
soon returned. 1 

In January, 1879, a lady called upon me having a frac- 
ture of the styloid process of the radius, which had occurred 
about four months previously. The fragment was tilted 
forwards and carried slightly upwards by the action of the 
long supinator. It was movable. The motions of the 
joint were in no way interfered with, and the form of the 
wrist was natural. She was somewhat advanced in life, 
and suffered from pains and soreness about the joint, but 
ii- more than is usual after severe wrist-joint injuries. 
The character of the accident was not recognized by her 
surgeon, and no treatment had been adopted; nor is it to be 
supposed that the displacement could have been remedied, 
except by section of the tendon of the long supinator, if its 
existence had been recognized; and. if this had been done, 
I doubt whether she would have had a more useful arm than 
she has now. 

Dr. Wm. Hunt.- of Philadelphia, reported a case of this 
fracture, the result of a fall upon the hand, ami accompanied 
with considerable comminution. It became necessary to 
amputate the arm. and the opportunity was thus afforded to Radius with 
determine the exact nature of the lesion by dissection. epiphyses. 

iphyseal Separations. — This bone is formed from (FromGray.) 
three centres, namely, one for the .-haft and one for either ex- 
tremity. The shaft is ossified at birth. About the end of the second year 
ossification commences in the lower epiphysis, and it becomes united to 
the shaft at about the twentieth yea)-. The same process commences in 
the upper epiphysis ;it about the fifth year, and is completed by consolida- 
tion with the shaft at the age of puberty. 

I have met with no recorded examples of separation of the upper 



I 




Med., 1*". 
1 Hunt. Phil. Med. Tim. 380, p. 26. 



Fi; \( TURES OF THE ULNA. 

epiphysis, and the examples of separation of the lower epiphysis have 
seldom been clearly made out. I have already mentioned one as having 
been reported by Roberl Smith. He speaks also of other cases occurring 
in conjunction with a separation of the lower end of the ulna, and 
which, he thinks, are Liable to be mistaken for dislocations. 1 

Malgaigne says thai we have reasons to suspect this accident when 
the fracture occurs in persons under twenty years of age. Cloquet 
ascertained its existence by a dissection in a child of twelve years; Roux 
also in a child whose age is not given, and Voillemier produced it easily 
in tln i dead bodies of children, and once in the body of a robust man of 
twenty-four. 2 Schmit? and Gardner 4 have also noticed the frequency of 
the epiphyseal separation when, in the case of infants, the fracture is 
caused by avulson upon the cadaver. The experiments of Dr. Girdner, 
made at my request, also showed, that in early life avulsion sometimes 
caused a fracture just above the epiphysis, sometimes a bending of the 
bone, without fracture, and sometimes only a rupture of the ligaments. 
I think I have broken the radius at the epiphyseal junction in some of 
my experiments of forced flexion in adult females. 

The treatment of this accident will not demand any special considera- 
tion, since it will not differ essentially from the treatment required in a 
fracture occurring at the same point. 

Belayed or Non-union of Fractures of the Radius. — Muhlenberg in 
his tables lias recorded 23 cases, of which 17 are reported as having 
been cured, and in 6 the attempts to cure have failed. Resection and 
drilling furnish the largest percentage of cures. I have never met with 
an example of non-union in a fracture of the lower end of the radius. 



CHAPTER XXIII. 

FKACTTJRES OF THE ULNA. 

^ 1. Fractures of the Olecranon Process. 

Causes. — My records furnish me with accounts of only 19 of these 
fractures, and, so far as I have been able to ascertain, all were occa- 
sioned by falls upon the elbow, or by blows inflicted directly upon the 
part. Malgaigne has, however, been able to collect accounts of six 
examples of fracture of the olecranon, produced, as is affirmed, by the 
violent action of the triceps; as in pushing with the arm slightly flexed, 
in throwing ;i hall, in plunging into the water with the arms extended, 
ere: hut only four of these reported examples does he think are suffi- 
ciently authenticated to entitle thou to be received as facts; nor do I 
think it possible to affirm positively that in any instance, where the whole 

i Roberl Smith. ..p. .it., p. 164. 2 MalsnuVne, op. cit. 

•nit. These de Paris, 1878, No. 114. 
* Girdner, Jno. EL, Med. Rec., Feb. 20, 1881. 



FRACTURES OF THE OLECRANON PROCESS. 357 

process is broken off, the triceps alone has occasioned the separation. 
For example. Capiornont reports the case of a cavalier, who, being in- 
toxicated, was thrown head-foremost from his horse, and, striking probably 
upon his head, was found to have broken the olecranon process. We do 
not. in this example, see evidence alone of a forcible contraction of the 
triceps, but also of violent pressure against the hand and in the direction 
of the axis of the forearm toward the elbow-joint, by which the olecra- 
non process might have been so thrown forwards against the fossa of the 
humerus as to cause its separation. The same explanation might apply 
to several of the other examples. 

Point and Direction of Fracture; Displacement, etc. — The process 
may be broken at its summit, at its base, or intermediate between these 
two extremes, the last of which is the most common. 

Tt is probable that when the action of the triceps alone has produced 
the fracture, it will be found that only that portion which receives the 
insertion of the triceps has been broken off. Malgaigne, who has been 
able to find upon record only two cases of a fracture of the extreme 
end of the process, declares that they were both occasioned by muscular 
action. 

Fractures of the middle are generally transverse, or only slightly 
oblique, occurring in the line of the junction of the epiphysis with the 
diaphysis. 

Fractures through the base are generally quite oblique, the line of 
fracture extending from before downwards and backwards, so that not 
only the whole of the process, but a portion of the back of the shaft is 
carried away; and this accident can scarcely happen, except by a blow 
received upon the front and lower end of the humerus, while the arm is 
extended ; or by a blow upon the back of the forearm, whether the arm 
be in a position of flexion or extension, received at a point a little below 
where the shaft of the ulna joins the olecranon. 

The only displacement to which the upper fragment seems to be liable, 
i> in The direction of the triceps; and the degree of this displacement 
does not depend bo much upon the 

point at which the fracture lias taken FlG> 112- 

place as upon the violence which has 
occasioned it. the extent of the dis- 
ruption of tin- ligaments, aponeurosis 
of the triceps and of the capsule, and 
upon whether, since the accident, 
the arm has been flexed or kepi ex- 
tended. 

In five instances I hare found 
distinct crepitus immediately after 
tin- fracture has occurred, produced ^ . ,,.« . 

'1 Fracture at the base. 

by "iily moving the fragment later- 
ally, showing plainly that little or no displacement had taken place. 
The following example will show also that this displacemenl does Dot 
always happen eveu after the lapse of several days, and where no surgical 
treatment has been adopted. 

Samuel Duckett, aet. 14. foil upon the point of the dhow, and two 




358 FBACTURES OF THE ULNA. 

days after was admitted !<> the Buffalo Hospital of the Sisters of Charity. 
The elbow was then much swollen, but no crepitus could be detected, 
and he could Dearly straighten his arm by the action of the triceps. On 
the sixth day, the Bwelling having sufficiently subsided, a distinct crepi- 
tus was discovered when the olecranon process was seized between the 
fingers and moved laterally. We extended the arm immediately, and 
applied a long gutta-percha splint to the whole front of the arm and fore- 
arm, securing it in place with a roller. On the eleventh day, five days 
after the first dressing, the splint was taken off and its angle at the 
elbow-joinl slightly changed; and this was repeated every day until the 
twenty-second from the time of the accident. The splint was then finally 
removed, when the fragment was found to be united without any per- 
ceptible displacement, and the motions of the joint were unimpaired. 

It must not be interred, however, that it is always prudent to leave 
this fracture thus unsupported, since it has occasionally happened that 
the displacement, which did not exist at first, has taken place to the 
extent of* half an inch or more, after the lapse of several days. Mr. 
Earle mentions n case in which the separation did not take place until 
the sixth day. when it was occasioned by the patient's attempting to tie 
his neckcloth. 

Symptoms. — The usual signs of a fracture of the olecranon process 
arc. when the fragments are not separated, crepitus, discovered especi- 
ally by seizing the process and moving it laterally; or, when displace- 
ment ha- actually taken place, the crepitus may be discovered sometimes 
by extending the forearm, and pressing the upper fragment downwards 
until it is made to touch the lower fragment; the existence of a palpable 
depression between the fragments, partial flexion of the forearm, and 
inability on the part of the patient to straighten it completely, or even 
to ilex the arm in some cases. If the fragments do not separate, gentle 
flexion ami extension of the arm, while the finger rests upon the process, 
may enable us to detect the fracture. 

It will sometimes happen that, owing to the rapid occurrence of tume- 
faction, the evidence of a fracture will be quite equivocal: and, in all 
cases where a severe injury has been inflicted upon the point of the 
elbow, it will be well to suspend judgment until, by repeated examina- 
tion-, made on successive days, the question is determined. Meanwhile, 
the arm ought to be kept constantly in an extended position, as if a frac- 
ture was known to exist. 

Prognosis. — In a large majority of cases this process becomes re- 
united to the shafl by ligament, which may vary in length from aline 
to an inch or more, and which is more or less perfect in different cases. 
Sometimes it is composed ,,f two separate bands, with an intermediate 
Bpace, or the ligamenl may have several holes in it; at other times it is 
composed in part of bone and in part of fibrous tissue; but most fre- 
quently ir [g ;. single, firm, fibrous cord, whose breadth and thickness are 
less than that of the process to which it is attached. 

If the fragments are maintained in perfect apposition, a bony union 
may occur, vet it i- not invariably found to have taken place, even under 
these circumstances. Malgaigne thinks, also, he has seen one case in 
which there was neither bone nor fibrous tissue deposited between the 



FRACTURES OF THE OLECRANON PROCESS. 



359 



fragments. This was an ancient fracture at the base of the olecranon; 
the superior fragment remained immovable during the flexion and exten- 
sion of the arm. yet it could be moved easily from side to side. 

In my own cases I have five times found the fragments united with- 
out any appreciable separation, and have presumed that the union was 
bony. One of these examples I have already mentioned ; the second 
was in the person of a lady, aged about forty years, who, having fallen 
down a flight of steps on the 8th of September, 1857, sent for me imme- 
diately. I found a large bloody tumor covering the elbow-joint, but 
there was no difficulty in detecting a fracture of the olecranon process. 
It was easily moved from side to side, and this motion was accompanied 
with a distinct crepitus. During the first week the arm was only laid 
upon a pillow, but as it was found to become gradually more flexed, and 
the swelling having in a great measure subsided, the arm was nearly, 
but not quite, straightened, and a long gutta-percha splint applied to the 
palmar surface of the forearm and arm. The fragments united in about 
twenty or twenty-five days, and without separation, so far as could be 
discovered in a very careful examination. 

The third example to which I have referred, occurred in a boy four- 
teen years old, and was treated by Dr. Benjamin Smith, of Berkshire, 
Massachusetts. Sixty-nine years after, he being then eighty-three years 
• •id. I found the olecranon process united apparently by bone, but to that 
day lie had been unable to straighten the arm completely, or to supine it 
freely. 

In one instance I found the fragment, after the lapse of one year, 
united by a ligament, which seemed to be about one-quarter of an inch 
in length, and the arm appeared to be in all respects as perfect as the 
other. He could flex and extend it freely. 

In the two following examples, also, the bond of Fig. 113. 

union was ligamentous : 

John Carbony, set. 18, having broken the ole- 
cranon, it was treated with a straight splint. Nine 
- after. I found the process united by a liga- 
ment half an inch in length, and he could nearly, 
but not entirely. Btraighten the arm. In all other 
ects the functions and motions of the ami were 
pert' 

A lad, «t. 15, was brought to me by Dr. Lauder- 
dale, 'Hint surgeon in the town of Gen- 

I '".. X. V.. whose olecranon process 
had been broken by a fall six months before, and at 
the same time the head of the radius had been dis- 
located forwards. I found the radius in place, and 
the olecranon process united by a ligament about 
half an inch in length. Be was not able to straighten 
the arm completely, the forearm remaining at an 
angle of 45° with the arm. 

Treatment. — It will surprise the student who is yet unacquainted 
with the literature of our science, to learn thai in relation to the treat- 
ment of a fracture of* the olecranon process, a wide difference of* opinion 




Union by ligament, 



FRACTURES OF THE ULNA. 

has been entertained as to what ought to be the position of the arm 
and the forearm, in order to the accomplishment of the most favorable 
results; and that, while some insist upon the straight position as essen- 
tial to success, others prefer a slightly flexed position, and still others 
have advocated the right-angled position. Thus Hippocrates, and nearly 
all of the earlier Burgeons, down to a period so late as the latter part 
of the Last century, directed that the arm should be placed in a position 
of* semiflexion: Boyer, Desault, and, after them, most of the French 
Burgeons of our own day. prefer a position in which the forearm is very 
slightly bent upon the arm ; while Sir Astley Cooper, and a large 
majority of the English and American surgeons, employ complete or ex- 
treme extension. 

The arguments presented by the advocates and antagonists of these 
various plans deserve a moment's consideration. 

In favor of the position of semiflexion, requiring no splints, and, in the 
opinion of some writers, not even a bandage, but only a sling to support 
the forearm, it is claimed that it leaves the patient at liberty at once to 
walk about and to move the elbow-joint freely, so soon at least as the 
subsidence of the swelling and pain will permit, and that in this way the 
danger of anchylosis is greatly diminished; that, moreover, if anchylosis 
should unfortunately occur, the limb is in a much better position for the 
proper performance of its most ordinary functions than if it were ex- 
tended. Some have also added to this argument a statement that a 
fibrous union, under any circumstances, is inevitable, and that it is a 
matter of little consequence whether the ligament thus formed is long or 
short, since in either condition it will be ecpially serviceable. 

In reply to these statements, it may be said briefly that they are nearly 
all based upon false premises, or that they have been proved in them- 
selves to he essentially erroneous. 

Anchylosis i- always a serious event, which by all possible means the 
Burgeon will seek to prevent, but position has nothing to do with deter- 
mining this result : when it does occur, it may usually be ascribed either 
to the Beverity and complications of the original injury, to the violence 
of the consequent inflammation, or to having neglected, at a proper 
period and with sufficient perseverance, to move the joint. 

Thai a fibrous union i< inevitable under any circumstances, has been 
proved to be an error; and while a short ligamentous union, such as is 
usually obtained when the arm is kept straight, may serve its purposes 
quite as well ;is ; , bony union, yet a long fibrous union, such as must 
very often he obtained when the arm is kept at a right angle, would 
seriously impair the usefulness of* the limb. 

The only argument which remains, and which really possesses any 
weight, is. that, if permanent anchylosis does actually occur, the arm, 
when semiflexed, i< in ;i better position for the performance of its ordi- 
nary functions; and this, considered as an argument in favor of the 
universal or even general adoption of the flexed position, is successfully 
met by a statement of the infrequency of* permanent anchylosis after a 
simple fracture, when the case ha- hem properly treated, whether by the 
flexed or straight position : while, if the limb is flexed, a maiming, as a 



FEACTUEES OF THE OLECRANON PEOCESS. 361 

result of the great length of the intermediate ligament, is quite as likely 
to occur. 

Yet if. in any case, from the great severity and complications of the 
injury, especially in certain examples of compound and comminuted frac- 
ture, it ay ere to be reasonably anticipated that permanent bony anchylosis 
must result, or even where the probabilities were strongly that way, the 
surgeon might be justified in selecting for the limb, at once, the position 
of semiflexion ; or he might leave the arm without a splint, and at liberty 
to draw up spontaneously and gradually to this position, as it is always 
very prone to do. 

In favor of moderate, but not complete extension, it is claimed that it 
is less fatiguing than the latter position, while it accomplishes a more 
exact apposition of the fragments, if they happen to be brought actually 
into contact. 

I am unable, however, to understand how the apposition can be ren- 
dered less exact by complete extension, unless by this is meant a degree 
of extension beyond that which is natural, and which, I am well aware, 
is permitted to the elbow-joint when this posterior brace is broken off. 
It would certainly derange the fragments to place the arm in this ex- 
treme condition of extension — that is, in a condition of extension ap- 
proaching dorsal flexion, which is beyond what is natural. Indeed, 
perhaps we may admit that, in order to perfect apposition, the extension 
ought to be less by one or two degrees than what is natural, sufficient to 
compensate for the trifling amount of effusion which may be presumed 
to have occurred in the olecranon fossa, and which would prevent the 
process from sinking again fairly into its fossa. 

As to its being less fatiguing, it is well known to those accustomed to 
treat fractures of the thigh by permanent extension that the muscles 
rapidly acquire a tolerance, which soon dissipates all feeling of fatigue, 
and that, after a few hours, or days at most, the patients express them- 
selves as being more comfortable in this position than in the flexed. 

Finally, the advocates of complete, natural extension claim that in 
this position alone is the triceps most perfectly relaxed, and conse- 
quently the most important indication, namely, the descent of the ole- 
eranon, most fully accomplished. In this opinion we also concur; and 
regarding all other considerations, in the early days of the treatment, 
as secondary to this one, we unhesitatingly declare our preference for 
what has been called the "position of complete extension," as opposed 
to flexion, semiflexion, or extreme extension. 

It only remains for us to determine by what means the limb can be 
best maintained in the extended position, and the olecranon process most 
easily and effectually secured in place. 

For this purpose a variety of ingenious plans have been devised, such 
as the compress and "figure-of-8" bandage of Duverney, without splints: 
or a similar bandage employed by Desault, with the addition of a long 
splint in front: the circular and transverse bandages of Sir A^tley 
Cooper, with lateral tapes to draw them together, to which also a splint 
was added; and many other modes not varying essentially from those 
already described, hut nearly all of which are liable to one serious ob- 
jection, namely, thai if they are applied with sufficient firmness to hold 



362 



KIIACTURES OF THE ULNA. 



upon the fragment, and Boyer says they "ought to be drawn very 
tight," they Ligate the limh so completely as to interrupt its circulation, 
and expose the limh greatly to the hazards of swelling, ulceration, and 
even gangrene. II<>w else is it possible to make the bandage effective 
upon a small fragment of bone, scarcely larger than the tendon which 
envelops its upper end, and with no salient points against which the 



Fig. 114. 



~^^ 




Sir Astley Cooper's method. 

compress or the roller can make advantageous pressure? If, then, these 
accidents — swelling, ulceration, and gangrene — are not of frequent oc- 
currence, it is only because the bandage has not been generally applied 
"very tight," and while it has done no harm, it has as plainly done no 
good. 

The dangers to which I allude may be easily avoided, without relax- 
ing the security afforded by the compress and bandage, by a method 
which is very simple, and the value of which I have already sufficiently 
determined by my own practice. 

The surgeon will prepare, extemporaneously always, for no single 
pattern will fit two arms, a splint, from a piece of thin, light board. 
This must be long enough to reach from near the wrist-joint to within 

Fig. 115. 




The author's method when the fragments are widely separated. 

three or four inches of the shoulder, and of a width nearly or quite equal 
to the widest part of* the Limb. Its width must be uniform throughout, 
except that, a1 a point corresponding to a point three inches, or there- 
about.-, below the top of* the olecranon process, there shall be a notch 
"ii each Bide, or a slight narrowing of the splint. One surface of the 
splint is now to be thickly padded with hair or cotton-batting, so as to 
lit all of* the inequalities of the arm, forearm, and elbow, and the whole 
covered neatly with a piece of cotton cloth, stitched together up*on the 



FRACTURES OF THE OLECRANON PROCESS. 308 

back of the splint. Thus prepared, it is to be laid upon the palmar sur- 
face of the limb, and a roller is to be applied, commencing at the hand 
and covering the splint, by successive circular turns, until the notch is 
reached, from which point the roller is to pass upwards and backwards 
behind the olecranon process and down again to the same point on the 
opposite side of the splint: after making a second oblique turn above 
the olecranon, to render it more secure, the roller may begin gradually 
to descend, each turn being less oblique, and passing through the same 
notch, until the whole of the back of the elbow-joint is covered. This 
completes the adjustment of the fragments, and it only remains to carry 
the roller again upwards, by circular turns, until the whole arm is 
covered as high as the top of the splint. 

The advantage of this mode of dressing must be apparent. It leaves, 
on each side of the splint, a space upon which neither the splint nor 
bandage can make pressure, and the circulation of the limb is, therefore, 
unembarrassed, while it is equally effective in retaining the olecranon in 
place, and much less liable to become disarranged. 

Before the bandage is applied about the elbow-joint, the olecranon 
must be drawn down, as well as it can be, by pressure with the fingers, 
and a compress of folded linen, wetted to prevent its sliding, must be 
placed partly above and partly upon the process ; at the same time, 
also, care must be taken that the skin is not folded in between the 
fragments. 

When the fragments are not much, or at all separated, and conse- 
quently no such force is required to draw down the upper fragment, and 
when, from the nature of the injury, there is little cause to anticipate 
much swelling, a splint may be employed, constructed like that recom- 
mended by Sir Astley Cooper, made of light wood, curved to fit the 
limb, or of gutta percha, gum-shellac cloth, or sole-leather. This should 
be covered with a flannel or cotton sack, and then secured in place by a 
roller. The sack will enable the surgeon to stitch the roller to the 
splint, and he can thus employ effectively the oblique and figure-of-8 
tarns about the elbow-joint. Indeed, the latter method will prove ade- 
quate in most cases, while it is less cumbrous than that which I have 
first described as being required when the separation is very great, and 
the injuries unusually severe. 

The dressing ought, no doubt, to be applied immediately, since, if we 
wait, as Boyer seems to advise, until the swelling has subsided, it will 
be found much more difficult to straighten the arm completely than it 
would have been at first, and the olecranon process will be more drawn 
up and fixed in its abnormal position. Something will be gained by 
these means, adopted early, even if the bandage cannot be applied 
tightly: and moderate bandaging will not in any way interfere with the 
proper and successful treatment of the inflammation. We must always 
keep in mind, however, the fact that the fracture being usually the 
result of a direct blow, considerable inflammation and swelling around 
the joint are about to follow rapidly; and on each successive day. or 
oftener if necessary, the bandages must be examined carefully, and 
promptly loosened whenever it seems to be accessary. For this purpose 
it i- better not to unroll the bandages, but to cut them with a pair of 



364 FRACTURES OF THE ULNA. 

scissors, along the face of* the splint, cutting only a small portion at a 
time, and as they »lra\\ back, stitch them together again lightly; and 
thus proceed until the whole lias been rendered sufficiently loose. 

A< soon as the inflammation has subsided, and as early sometimes as 
the fifth or seventh day, the dressing ought to be removed completely; 
and while the fingers of the surgeon sustain the process, the elbow 
ought to be gently and slightly flexed and extended two or three times. 
From this time forwards, until the union is consummated, this practice 
should be continued daily, only increasing the flexion each time, as the 
inflammation and pain may permit. If it is thought best, at length, to 
change the angle of the arm, and to flex it more and more, it may be 
done easily by substituting a very thick sheet of gutta percha for either 
of the other forms of dressing. 

Dieffenbach has several times, in old fractures of both the olecranon 
and patella, where the fragments were dragged far apart, divided the 
tendons, so as to be able to bring the two portions together, and, by 
friction of them one upon the other, has endeavored to excite such action 
as might end in the formation of a shorter and firmer bond of union. In 
-Mine instances, it is said, considerable benefit was obtained, after all 
other means had failed : in others, the result was negative. One example 
of an old ununited fracture of the olecranon is mentioned, in which he 
divided the tendon of the triceps, secured the upper fragment in place, 
and every fourteen days rubbed it well against the lower one ; in three 
month- -'the union was firm."' 1 

Mr. Lister, in the case of a patient whose olecranon had been broken 
many months before, and not satisfactorily united, exposed, with anti- 
septic precautious, the fragments and brought them together with strong 
silver wire, thus securing a bony union without any accident. He has 
repeated this operation in an analogous case, with like success. 2 

Rose, 3 Mac Cormac, 4 and Lesser 5 have each reported one example of 
success in the -a me class of cases. 

Neither the methods of Dieffenbach nor of Lister are without their 
hazards, and no doubt ought to be reserved for extreme cases. 

Plaster-of-Paris, or any other form of immovable dressing, which ex- 
cludes the surface of the limb from observation, and which is made 
sufficiently tight To hold permanently upon the upper fragment, exposes 
the patients to the dangers of swelling and gangrene. If not sufficiently 
tight to expose to these dangers, they serve no other purpose than to 
keep the limb straight. 

Iii 1850, Rigaud, of Strasbourg." introduced two screws into the upper 
and lower fragments, respectively, and drew them together with a string. 
The screws remained in position two months, and the result was a "per- 
fect cure." One might wish to know more precisely, in what sense it 
was " perfect." 

Dieffenbach, American Journal of the .Medical Sciences, vol. xxix. p. 478; from 

Wochenschrift, Oct. 2, 1841. 
!.-:■ p, The Lancet, June 4, 1881, p. 014. 
Boee, The Lancet, 1880, vol. 1. p 

• IfacCormac, The Lancet, June 4, 1881, p. 913. 

L* Bser, Quentin, Bruch. dee Olek., [naug. Diss., Bonn, 1881. 

• R | Med. Ohir., I860. 



CORONOID PROCESS OF THE ULNA. 365 

In 1864, Busch applied a plaster-of-Paris splint, furnished with a 
fenestra at the posterior part of the elbow : after which he made fast a 
metallic clamp, one point of which penetrated the upper fragment, and 
the two lower points were made to penetrate the plaster of Paris ; by 
means of a screw the fragments were approximated. 1 Madelung 2 has 
three times adopted the same method : in one of which the method had 
to he abandoned on account of the " indocility " of the patient. Pingaud 3 
reports, also, an example of success by this method. 

Lauenstein proposes to aspirate the joint where there is much inter- 
articular effusion, in order to secure better apposition of the fragments. 
The fact that he has seen no serious results from this practice, will hardly 
justify the prudent surgeon in performing an operation of so much hazard 
and of so little probable utility. 

Separation of the Olecranon while in its Epiphyseal State. — Recently 
a gentleman called upon me with his son, aged seven years, who had an 
unreduced dislocation of the radius and ulna backwards of nine weeks' 
standing. While reducing this dislocation, it being necessary to flex the 
arm forcibly, the epiphysis constituting the olecranon process gave way, 
and became separated from one-half to three-quarters of an inch. This 
is the only example of separation of this epiphysis which has come to 
my knowledge. I have, however, twice since broken the olecranon in 
attempts to reduce old dislocations of the radius and ulna backwards, 
and I have not regretted the occurrence, since it enabled me to reduce 
the dislocations without cutting the triceps. 

§ 2. Coronoid Process of the Ulna. 

Dissections have established the existence of this fracture in the living 
subject. The fact, however, that the number of authentic observations 
i- very small, seems to imply that the accident is infrequent, and 
especially as a simple fracture, unassociated with other fractures. 

Malgaigne thought that it was more frequent than the small number 
of reported examples would lead us to suppose; and especially because 
he had noticed how often the summit of the process is broken off when 
dislocation of the radius and ulna backwards is produced on the 
cadaver. In three or four cases also of dislocations of these bones 
backward- and inwards, which had come under his notice he was unable 
to feel this process, and he, therefore, thought it probable that it was 
broken off. Other surgeons have thought also that it was not an infre- 
quent accident in connection with a dislocation, Fergusson has, indeed, 
made the extraordinary statement that in dislocations of the radius and 
ulna backwards "the coronoid process will probably be broken." 

( linical Examples not Verified by Dissection. — In the two following 

. the existence of a fracture of the coronoid process was at firsl 

suspected by me, but I have now very little doubt that my diagnosis was 

incorrect. I -hall relate them, however, as examples of those accidents 

which are likely to be mistaken for fracture of this process. 

1 Busch, P'-in^-t, <>1>. ':it.. p. 397. 

2 Bdadelung, Quentm, op. cit. 

3 Pingaud, Diet. Encyc., Art. Coude, p. 639 i 1878). 



366 FRACTURES OF THE ULNA. 

A laboring man. aged about twenty-five years, had been seen and 
treated by another surgeon, for what was supposed to be a simple dislo- 
cation of* the radius and ulna backwards. The surgeon thought he had 
reduced the dislocation very soon after the accident. On the following 
day he found the dislocation reproduced, and he requested me to see the 
patient with him. The arm was then much swollen, but the character 
of the dislocation was apparent. By moderate extension, applied while 
the arm was Blightly ilexed, and continued for a few seconds, reduction 
was again effected, the bones returning to their places with a distinct 
Bensation; but on releasing the arm the dislocation was immediately re- 
produced. These attempts to reduce and retain in place the dislocated 
boms were repeated several times during this day and on subsequent 
da vs. but to no purpose, and the patient was dismissed after about two 
weeks with the bones unreduced. 

The impossibility of retaining the bones in place, and the existence of 
an occasional crepitus during the manipulation, inclined me to believe 
at the time that the dislocation was accompanied with a fracture of the 
coronoid process. 

Another similar case has since presented itself in a child nine years 
old, and in which the subsequent examinations not only demonstrated the 
non-existence of a fracture, but also rendered doubtful the justness of 
the conclusions which I had drawn in the case just related. 

This lad fell, November 4, 1855, and his parents immediately brought 
him to me; but as he lived many miles from town, I did not see him 
until eighteen hours after the injury was received. I found the arm 
much swollen, slightly flexed, and pronated. Flexion and extension of 
the arm were very painful, the pain being referred chiefly to the front 
of the joint, near the situation of the coronoid process ; and at this point 
also there was a discoloration of the size of a twenty-five cent piece. 
Flexing the forearm moderately upon the arm and making extension, the 
bones came readily into place, but without sensation of any kind, either 
a -nap or a crepitus. That the bones had now resumed their position, 
however. I made certain by a very careful examination with the hand 

Fig. 116. 



Fracture of the coronoid process. 

and by measurement, yet they would not remain in place one moment 
when the extension was discontinued. The reduction was made several 
times, and constantly with the same result. We then applied a right- 
angled Bplinl to the arm, having first reduced the bones, and thus were 
able to retain them in position. I believed that the coronoid process 
was broken, and so informed the surgeon, to whose care the boy returned. 
Five month- after, he was brought again to me, and I then found that 
the radius and ulna had been kept in place; the motions of the joint 
were perfect, and if the coronoid process had ever been broken it was 
now again in it- natural position, and with every structure about it in a 
condition ;i- complete as it was before the accident. 



COROXOID PROCESS OF THE ULNA. 367 

Malgaigne mentions three reported examples, namely, one published 
by Combes Brassard, an Italian surgeon, in 1811, which Brassard saw 
only after a lapse of three months : one seen by Pennock, and published 
in the Lancet in 1828. the patient then being sixty years old. and the 
accident having occurred when he was a young man ; the third was seen 
by Sir Astley Cooper, several months after the accident, and is reported 
by himself in his excellent treatise on Fractures and Dislocations. bay- 
Sir Astley: " It was thought, at the consultation which was held about 
him in London, that the coronoid process was detached from the ulna." 
This was the only living example seen by Sir Astley in his long and 
immensely varied surgical practice ; and even here we cannot fail to 
notice the apparent reserve with which he expresses his opinion — ; ' It 
was thought at the consultation.'' 

Dorsey says that Dr. Physick once saw a fracture of the coronoid pro- 
The symptoms resembled a luxation of the forearm backwards. 
•• except that when the reduction was effected, the dislocation was re- 
peated, and by careful examination, crepitation was discovered. The 
forearm was kept flexed at a right angle with the humerus. The ten- 
dency of the brachialis internus to draw up the superior fragment was 
counteracted in some measure by the presssure of the roller above the 
elbow. A perfect cure was readily obtained/' 1 In 1830, Dr. "William 
M. Fahnestock reported a case occurring in a boy, who, having fallen 
from a haymow, received the whole weight of his body ; ' on the back 
part of the palm of the left hand," while the arm was extended forwards. 
It seemed to be a dislocation of the forearm backwards, but when reduced 
it was again immediately displaced, with an evident crepitus. The arm 

- secured in the angular splint of Dr. Physick and " recovered very 
speedily." 1 Dr. Couper, of the Glasgow Infirmary, also has reported a 
dislocation of the forearm backwards and outwards, occurring in a young 
man aged seventeen, and which he thinks was accompanied with this 
fracture. The dislocation was easily reduced, but returned again imme- 
diately on ceasing the extension. The fragment was not felt, nor does 
lie -peak of crepitus : the existence of the fracture being inferred from 
the fact that the bones would not remain in place without help. The 
forearm was placed across the chest, with the fingers pointing toward the 
opposite shoulder, and secured in this position with splints and a band- 
At the end of four week- union had taken place, with only slight 
deformity, although with some stiffness of the joint. 

In relation to this example, the editor remarks that the symptoma were 
not to his mind conclusive in determining the existence of a fracture of 
the coronoid process, and he inclines to the belief that it was rather an 
oblique fracture of the lower extremity of the humerus. " In cases like 
," he add.-. •• where very rare accidents are suspected, we think that 
unless the diagnosis is clear, the leaning should always be the other way: 
lean that, cceteru paribus, the symptoms should rather be referred 
to the common than the extraordinary injury. The contrary practice 
introduces a dangerous laxity in diag 

1 Doisey, Elem S . -rv. vol. i. p. 152. Philadelphia, 1813. 

3ci., vol. vi. | 
per. Med.-Chir. I: . vol. xi. p. 509. 






FRACTURES OF THE ULNA. 



Dr. Duer, of Philadelphia, lias reported a case which occurred in a 
boy >i\ years old, and in which he fell and moved the fragment with his 
fingers. It was complicated with a dislocation, which remained unreduced. 
Tin- case was last seen aboul seven weeks after the accident. 1 The 
Doctor ad«N : "It' at a later period we could be permitted to examine the 
patient, it is probable that the diagnosis might be rendered certain." 

In the American Medical Monthly for October, 1855, also, I find the 
reporl of a trial for malpractice, in which a lad nine years old received 
some injury aboul the elbow-joint which resulted in a maiming. The 
defendant claimed that there had been a dislocation of the forearm back- 
wards, accompanied either with a fracture of the trochlea of the humerus, 
or of the coronoid process of the ulna. 

Says Mr. Listen : "The coronoid process is occasionally pulled or 

pushed off from the shaft, more especially in young subjects. I saw a 

case of it lately, in which the injury arose in consequence of the patient, 

■a hov of eight years, having hung for a long time from the top of a wall 

by one hand, afraid to drop down;" 2 after whom Miller, 

Fig. 117. Erichsen, Skey, Lonsdale, and most of the Scotch and 

English surgeons have repeated the assertion that this 

process may be broken in this manner by the action of 

the brachialis anticus alone, yet no one of them has to 

this day seen another example. 

The explanation of the accident in the case of the 
boy, given by Liston, implies two anatomical errors: 
first, that the coronoid process is an epiphysis during 
childhood ; and second, that the brachialis anticus is in- 
serted upon its summit. The coronoid process is never 
an epiphysis, but is formed from a common point of 
ossification with the shaft; the olecranon process and 
the lower extremity of the ulna having also separate 
points of ossification; the olecranon becoming united 
to the shaft at the sixteenth year, and the lower epiphy- 
sis ;it the twentieth. Moreover, the brachialis anticus 
has its insertion at the base of the process and partly 
upon the body of the ulna, but in no part upon its sum- 
mit ; indeed, the process seems rather to be intended as 
a pulley over which the brachialis anticus may play ; 
resembling also somewhat, in its function, the patella; 
serving to protect the joint and perhaps the muscle itself 
from becoming compressed in the motions of the joint. 

I lertainly it could never have been broken by. the action 
pbysis. (From . J 

Gray.) ol this muscle, and the case mentioned by Mr. Liston 

niiiM find some other explanation. It may have been a 
rupture of the brachialis anticus itself, or of the biceps, or possibly a 
forward Luxation of the head of the radius. Either of these suppositions 
is more rational than the statement made by Mr. Liston, because either 
one of them is possible, while his supposition is impossible. 



1 Duer, Ain.-r. Journ. Med. Sci., Oct. 1863, p. 390. 
* Liston, Practical Surgery, p. 55. 



COROXOID PROCESS OF THE ULNA. 369 

Ulrichs, 1 Battanis.' Laugier, 3 Lorinzer, 4 Zeis, 5 Lotzbeck, 6 Comoy, 7 
Gripat, 8 have also reported clinical examples not verified by dissection. 9 

The first two of the above enumerated (Brassard's and Pennock's) 
were not satisfactory to Malgaigne : the third is spoken of cautiously by 
Sir Astley Cooper, as if it needed, in addition to his own great name, 
the indorsement of the "London council."' Dorsey reports his case 
upon hearsay, and the result is quite too satisfactory to give it much 
claim to credibility. Falmestoek's case is, to my mind, far from being 
fully proven. Couper's case is doubted by Dr. Johnson ; and the New 
Hampshire case was not made out satisfactorily to either the jury or the 
medical men. Liston's case was simply impossible. Duer's case could 
have been better verified at a later period. 

Poinsot, speaking of some of the more recently reported clinical cases, 
Bays: ''The first case of Ulrichs's is more than doubtful; the author 
himself admits that the diagnosis was made by exclusion. As to the 
case of Battams, the diagnosis is based solely upon the ease with which 
the dislocation was produced and reproduced ; it is, therefore, truly a 
claim on principles, the point at issue being to know precisely if that 
tendency to be reproduced was really to be attributed to the fracture of 
the apophysis. The same remark applies to the cases of Lorinzer and 
<>f M. Richet. I have already said why I thought that Laugier's case 
and my own should be rejected. Zeis, in his case, does not define in any 
way the character of the injury. There only remain, therefore, the 
3 of Lotzbeck. where the diagnosis seems to be clothed with all the 
_niarantees; but is it not to be somewhat wondered at that the same 
surgeon should have met with three cases so absolutely analogous, and 
terminating with such equally happy results ? At all events, these 
9 <:an only be considered as exceptions." 

In the case described by Laugier, a boy get. 12, had fallen upon the 
right hand, the forearm being slightly flexed. He was admitted to the 
hospital, July 6, 1840, with a dislocation of the radius and ulna back- 
ward-. The dislocation was easily reduced, and the motions of the joint 
were completely restored. The swelling having subsided after 10 or 12 
day-, a -mall, very hard, circumscribed and slightly movable tumor 
was observed ;t little below the bend of the elbow, which interfered 
with flexion. 

Having described tin- case, of which I have only given a summary, 
Poinsot relates what lie regarded as a similar case sent to him by his 
colleague, M. Gautier. A man. twenty days before, had fallen upon his 
hand. Gautier found a dislocation, which he reduced easily, and the 

1 Ulrichs, Deute. Zeits. fur Chir., t. 10, Nov. 1878. 

2 Battams, The Lancet, L878, vol. 2, \>. 607. 
L . ., .. B :• • ( Mr., l-l". 

1 Lorinz ,Z - lei K K. Gee. der Ac. fur Wein, vii. Jarh., Heft 7. 

/. j, 8 nmidt'a Jahr. fur 1866, p. 134 
6 Lotzbeck, Die Frak. Pr. Cor., kunchen, 1866. 
C >moy, Frac. de L'Apoph. Cor. etc., These Pari-. 1*81. 
pat, Bull. Soc. Anat., 1 - 
' When speaking of fractures of the head of the radius T have -aid, thai Dr. Bodges 
had three times found the eoronoid process broken in that connection. I ought to 
have said he had found in Vie reported dissections. To these I shall hereafter r< 

24 



370 FRACTURES OF THE ULNA. 

motions ot* the joint were completely restored. When seen by Poinsot 
there existed a hard, circumscribed tumor, which seemed united to the 
tendon of the brachialis amicus. The limb could not be flexed well. 
Upon careful examination, Poinsot, who at first thought it might be a 
fracture of the coronoid process, decided that it was "an induration, 
Buch as results from certain contusions; and that opinion seems now to 
be confirmed by the researches of M. Charvot, on the transformation of 
sanguinolent deposits at the bend of the elbow. I believe that Laugier's 
case should receive the same explanation." 

Poinsot refers also to the two supposed cases reported by Lorinzer and 
Comoy, respectively, both accompanied with a dislocation backwards. 
In the first case there was marked bony crepitus in the region of the 
coronoid process, but Lorinzer was compelled to recognize the fact that 
no swelling existed in the supposed seat of fracture. In the second case, 
a fine and dry crepitus could be felt at the bend of the arm. Professor 
Richet. in whose wards the patient was, recognized a fracture, but could 
not fix its exact location. 

The three cases met with by Lotzbeck presented, says Poinsot, "a 
most complete similarity with each other. In the three instances, there 
was felt at the bend of the elbow a small tumor, hard and circumscribed, 
movable laterally, and giving rise to crepitation when moved. The 
displacement (twice both bones, and once the ulna only were dislocated) 
was easily reduced, but would be reproduced immediately. In the three 
cases the cure was accomplished and the movements of flexion were 
regained pretty promptly and with almost their normal freedom." 

Of the clinical case reported by Ulrichs, the same writer remarks : 
"A young boy fell upon his left side while helping to carry a beam whose 
weight was resting on his left forearm, which was bent at a right angle. 
He experienced a violent pain and could neither flex nor extend the 
forearm. The surgeon who was called felt a pretty obscure crepitus in 
the region of the bend of the elbow ; but there being no displacement of 
the bony prominences, the diagnosis of fracture of the coronoid process 
was made by exclusion." 

"M. J. Scott Battams, of Royal Free Hospital," says Poinsot, " thought 
he had to deal with a fracture of the coronoid process in the case of a 
man who, slipping on a sidewalk, had his elbow caught between his hip 
and the pavement. At first it was difficult to determine the nature of 
the lesion : the patient could, with pain it is true, extend and flex the 
forearm a little beyond a right angle. Supination and pronation were 
performed slowly, but well; the bony prominences of the elbow had 
kept their normal relations, and the head of the radius was in its or- 
dinary position. Up to that time the patient had supported the wounded 
arm with the other hand; suddenly he allowed it to drop, and at once 
the ulna was dislocated backwards, the radius remaining in place. This 
dislocation was reduced easily, but to be reproduced with the same 
facility. The limb was placed on an elbow-splint, which was allowed to 
remain for three weeks. At that time, there existed a small indurated 
growth on a level with the coronoid process, at the point where in the 
"beginning there ivas a bloody effusion. The movements, at first im- 
peded, were Boon completely regained." 



COROXOID PROCESS OF THE ULNA. 371 

Certainly it is not upon such testimony as this that we can rely to 
sustain Mr. Fergusson's opinion that this fracture is likely to occur in 
all dislocations of the forearm backwards, or of Malgaigne's conjecture 
that it is of more frequent occurrence than the published cases would 
seem to show. Nor will it be regarded as conclusive, that the beak of 
the process is often found broken after luxations made upon the subject ; 
since between luxations thus produced and luxations occurring in the 
living subject there exists this important difference, that, in the case of 
the latter, muscular action is the principal agent in the production of the 
dislocation, while in the former it is the external force alone which drives 
the bone from its socket. 

The fact, therefore, that so few cases have ever been reported, and that 
most of these are far from having been clearly made out, remains pre- 
sumptive evidence that the actual cases are exceedingly rare; but if to 
this we add such evidence as is furnished by actual dissections, and by 
examinations of the pathological cabinets of the world, we think the testi- 
mony is almost conclusive. 

Examples supposed to be established by dissection. — In 1834, M. 
Berard 1 examined the arm of a man who had been killed by a fall from 
a second story. The forearm was dislocated backwards. In attempts at 
reduction and redislocation, there was observed, under moderate pres- 
sure, a slight crepitation. There was found a fracture of the coronoid 
process, of the anterior third of the head, including a portion of the 
neck. Sir Astley Cooper 2 says that a person was brought to the dissect- 
ing-room at St. Thomas's Hospital, who had been the subject of this 
accident. u The coronoid process, which had been broken off within the 
joint, had united by a ligament only, so as to move readily upon the 
ulna, and thus alter the sigmoid cavity of the ulna so much as to allow 
in extension that bone to glide backwards upon the condyles of the 
humerus." Mr. Bransby Cooper adds, in a note, that the external con- 
dyle of the humerus was also broken and united by a ligament. 

Samuel Cooper describes, rather obscurely, a specimen contained in 
the University College Museum, "in which the ulna is broken at the 
elbow, the posterior fragment being displaced backwards by the action 
of the triceps ; the coronoid process is broken off; the upper head of 
the radius is also dislocated from the lesser sigmoid cavity of the ulna, 
and drawn upwards by the action of the biceps. In this complicated 
accident the ulna is broken in two places." 

Velpeau has also established by two autopsies the existence of a frac- 
ture of the coronoid apophysis. 

Dr. Charles Gibson, of Richmond, Va., has stated to me, by letter, 
that he has in hia possession a specimen of this fracture, evidently 
belonging to an adult. The process was broken transversely near its 
extremity, and has united again quite closely and without any displace- 
ment, and without ensheathing callus. 

Lotzbeck 3 has seen, as Ik- thinks, an ancient fracture of this process, 
in the cadaver, the line of fracture passing beneath the lesser sigmoid 
cavity and into the greater sigmoid cavity. The condyle was broken 

1 Berard, Die. de Med. Art. Coude. 

2 Sir A. Cooper, Dislocatipns and Fractures, p. 411. 3 Lotzbeck, loc. cit. 



372 FRACTURES OF THE ULNA. 

also, and was reunited by fibrous tissue and cartilage. The coronoid 
was united by bone, and loaded with osteophytes. 

ririehs 1 found, in a cadaver, a fissure of the summit of the coronoid 
process, caused by tortion or twisting of the forearm, without any other 
lesion of the bone. In a cadaver seen by Gripat, the coronoid process 
was fractured at its base, and the radius and ulna were dislocated back- 
wards and upwards. 

Allandale- also, having performed resection for an ancient dislocation, 
found this process fractured, and a bony callus had united the ulna to 
the humerus. 

Gurlt 3 has described a specimen, contained in the museum at Braun- 
schweig, illustrating a fracture of the extremity of the coronoid process. 
A small fragment was also broken from the ulnar side of the olecranon. 
Both fragments have united by bone. 

Say> Mr. Flower, Conservator of the Museum of the Royal College of 
Surgeons, "the cases that have been reported in which it has been 
observed in the living subject are exceedingly unsatisfactory." ..." I 
have been able to meet with but three or four specimens, and recorded 
post-mortem examinations of this injury" (alluding, I presume, to clin- 
ical cases). " One of the former is in the museum of Guy's Hospital. 
Another case is that of a man killed by a fell from the roof of St. 
George's Hospital; in whom the coronoid processes were found to be 
fractured, and the two bones of the forearm dislocated backwards on 
both sides." 4 The first of the specimens (Guy's Hospital) has been 
described by Mr. Bryant, 5 as having occurred in a woman seventy years 
old, and as having been caused by a fall upon the elbow. In addition to 
a fracture of the coronoid near its extremity, there was a comminuted 
fracture of the anterior third of the head of the radius. Indeed, it will 
be observed that in several of the cases verified by dissection, the fracture 
of the coronoid process was accompanied with other fractures in the 
vicinity of the joint ; a circumstance which would not usually permit 
them to be studied or classified as simple fractures. Perhaps, however, 
we ought to consider, from the frequency of its concurrence, a longitudinal 
fracture of the head of the radius as a natural complication of the frac- 
ture now under consideration, when it is caused by a dislocation of the 
radius and ulna backwards. 

In reference to the specimen belonging to my distinguished friend, 
Dr. Gibson, of Richmond, Va., notwithstanding the respect which I 
entertain for his opinion, I cannot avoid a suspicion that the bone was 
never broken at all, since I find it more easy to believe that he is deceived 
by certain appearances, than that it should have united by bone again, 
and so perfectly as not to leave any line of separation or degree of dis- 
placement. Certainly the fracture was too high to have been produced 
by the action of the muscle, if such a thing were ever possible; and if 
broken by a dislocation, which must have forced it violently from its 

" OTrichs, loc. cit. 2 Allandale. Med. Times and Gaz., May 25, 1875. 

3 Gurlt, Von den Knocken., 1862, vol. i. p. 41. 

* Flower, Holme-'- Surgery, 2d New York ed., vol. ii. p. 790. 

5 Bryant, System of Surgery, 1st London ed., pp. 939, 941. 



COROXOID PROCESS OF THE ULNA. 373 

position, as the ulna was driven upwards, it seems improbable that, if 
broken at this point, it could ever be made to unite again so perfectly. 

Poinsot, speaking of Lotzbeck's case, and after recapitulating in de- 
tail the anatomical conditions presented, concludes, that it " was much 
more probably a case of dry arthritis, following the fracture of the con- 
dyle, than a simultaneous fracture of the coronoid process and the ulna." 

Causes. — Judging from the clinical cases alone, it would seem that 
the most frequent cause of this accident is a fall upon the outstretched 
hand, and generally upon the palm of the hand ; the force of the blow 
being received upon the lower end of the radius, and, through its numer- 
ous muscles and ligamentous attachments, being indirectly conveyed to 
the ulna, producing a violent concussion of the coronoid process against 
the trochlea of the humerus, and resulting finally in a fracture of this 
process and a dislocation of both bones of the forearm backwards. The 
examples verified by dissection, however, seem to have been produced 
by a variety of causes. The gentleman seen by Sir Astley had fallen 
upon his extended hand while in the act of running. Brassard's patient 
had fallen also upon his hand with his arm extended in front. The same 
was the fact in the cases seen by Lorinzer, Richet, and Lotzbeck ; the 
latter of whom has recorded two cases due to this cause. Pennock's 
patient, a man of sixty years, had fallen upon the palm of his hand, 
and Fahnestock's fell upon the "back of the palm." In one of Lotz- 
beck's cases the fracture was supposed to be caused by extreme flexion 
of the forearm ; and in another case of supposed fracture, seen by Lotz- 
beck. it seemed to be the result of direct violence. While in a case seen 
by Ulrichs, a longitudinal fissure was caused by violent tortion or twist- 
ing of the forearm. In the case mentioned by Bryant, the patient fell 
upon the elbow. 

Symptoms. — Partial or complete displacement of the ulna, or of the 
radius and ulna backwards, accompanied with the usual signs of these 
luxations. In two of the examples mentioned by Malgaigne there was a 
luxation of the forearm backwards ; such was also the fact in the case seen 
by Fahnestock ; in Couper's case it was dislocated backwards and out- 
wards, and in Sir Astley 's case I infer that there was only a subluxation 
of the ulna backwards. In a case seen by Gripat, verified by an au- 
topsy, there was a dislocation of the ulna. In the cases of Lorinzer and 
Richet, both bones were dislocated backwards, and in two of those seen 
by Lotzbeck. A feeble crepitus has sometimes been recognized; and it 
is fair to presume that in some examples the fragment, carried forwards 
by being driven against the trochlea, may be felt displaced and movable 
in the bend of the elbow. We must be careful, however, not to mistake 
a hard nodule following traumatisms in this region, and the frequent 
occurrence of which has been signalized by Charvot, for the coronoid 
process. If only the summit is broken off, the brachialis anticus could 
have no influence upon it; but if it were broken dairly through the 
base, it might be displaced slightly in the direction of the action of this 
muscle. 

The symptoms, however, which have been regarded as most diagnostic, 
are the disposition to relaxation manifested in most of these examples 
when the extension ha- been discontinued. But it must not be forgotten 
that other conditions than a fracture of the coronoid process may cause 



374 FRACTURES OF THE ULNA. 

a relaxation, such as a fracture of the internal condyle, of the trochlea, 
or a splitting of the condyles, or some other derangement of the articular 
surfaces, or o\' the ligaments or muscles concerned in the articulation. 
Possibly, where the force applied lias been great, as in falls from a great 
height, the brachialis anticus may have been detached. 

Prognosis* — In the case of Cooper's patient, seen several months 
after the accident, the ulna projected backwards while the arm was ex- 
tended, but it was without much difficulty drawn forwards and bent, and 
then the deformity disappeared. He thought that during extension the 
ulna slipped hack behind the inner condyle of the humerus. Brassard's 
patient, seen after three months, retained the power of pronation and 
supination, with also extension, but flexion was impossible, the forearm 
being arrested in this direction by the small, slightly movable fragment 
of bone in front of the elbow-joint, and which was supposed to be the 
process itself. Pennock's old man, who had met with the accident in 
boyhood, had still the radius luxated forwards and outwards, aud the 
olecranon more salient backwards than in the sound arm. Extension 
and flexion were nearly but not quite complete. Fahnestock informs us 
that his patient " recovered completely," but whether without deformity 
or maiming we are not told. Couper says the bone was united in four 
weeks, and that only a slight deformity and a little stiffness remained. 
Physick's patient made a perfect recovery. 

"The same result/' says Poinsot, "followed in Dr. Scott Battams's 
patient, in whom the difficulty in flexion and extension which existed at 
first, disappeared in a few weeks. In the case of Allandale, the disloca- 
tion had remained unreduced, but no mention is made of the kind of 
dressing employed at the beginning. In Lorinzer's case, the movements 
of the elbow remained limited, the patient could only flex the forearm to 
a right angle. On the contrary, Richet's patient showed no remaining 
trace of the accident when she left Hotel-Dieu at the end of fifty-two 
days. It has already been seen that in Lotzbeck's cases, the result was 
no less favorable." 

Let us return to the examples verified by dissection and to the cabinet 
specimens. R ejecting the doubtful specimens belonging to Dr. Gibson, 
and that of Lotzbeck, also those of " Hodges, 1 of Gripat, and of Ulrichs, 
where there was no opportunity to get a history of the fracture, as well as 
that of Allandale, where it is difficult to determine what part of the tumor 
surrounding the humerus and ulna is due to the consolidation of the 
fracture." | Poinsot.) 

In the specimen described by Gurlt, without a history, the fragment 
i- united, in position, with exuberant callus on the anterior surface. 

And in tin- specimen referred to by Bryant, the coronoid process and 
;i portion of tin- head of the radius having been broken, bony union has 
taken place \\itliout displacement of either. 

Samuel < looper says thai in the case of the University College specimen 
the radius remains dislocated forwards and upwards, and the olecranon 
i- displaced backwards, hut he does not say whether the coronoid process 

1 The - Bodges probably here referred to, and reported first in 1866, vol. 75, 
p. 388, of the Boston Medical and Surgical Journal, and subsequently in vol. 96, p. 
the Bame journal, was not properly speaking a fracture of the coronoid process, 
but a longitudinal fracture of the upper end of the ulna. 



SHAFT OF THE ULNA. 375 

lias united, nor describe its position : but Sir Astley informs us that in 
the example seen and dissected by him the process was united by liga- 
ment, which was sufficiently long and flexible to allow the fragment to 
move upwards and downwards in the motions of flexion and extension. 

In the absence of other testimony, we may be allowed to express an 
opinion that when the fracture has taken place across the summit or 
above the insertion of the brachialis anticus, nothing but a ligamentous 
union can be regarded as possible, since the fragment can only derive 
nourishment from a few untorn fibres of the capsule and perhaps of the 
internal lateral ligaments : and although it may not be displaced, it can- 
not have the advantage of impaction, upon which alone, I suspect, a 
fracture of the neck of the femur within the capsule must rely for a bony 
union, if it ever does so unite. If, however, the fracture has taken place 
at the base, and fortunately it has not become much displaced by the 
force of the concussion against the humerus, it does not seem to me 
improbable that under favorable circumstances a bony union might occur. 
It will be remembered that a good portion of the attachment of the 
brachialis anticus is still below the fracture, and the remaining fibres are 
not therefore very likely to displace the fragment, especially when the 
arm is sufficiently flexed, so as properly to relax this muscle. 

It will be of small importance, however, whether the union is bony or 
ligamentous, provided only there is not great displacement. 

Treat ment. — Whatever view we take of the mechanism or pathology 
of this accident, the rational mode of treatment would seem to be to flex 
the arm at a right angle, and retain it a sufficient length of time in that 
position : not forgetting, however, the danger of anchylosis from long- 
continued confinement in one position. 

An angular splint may be useful in preventing motion at first, but I 
think it ought not to be continued beyond seven or ten days at the most. 
After tli is. a simple sling is all that is necessary, since from this period 
Bome motion must be given to the joint if we would take the proper pre- 
cautious to prevent stiffness. Sir Astley Cooper thought the limb ought 
to be kept immovable three weeks, and Yelpeau preferred four : but I 
cannot agree with them, believing that the question of the future mobility 
of the elbow-joint is vastly more important than the question of a bony 
or ligamentous union between the fragments. Couper says that he 
adopted in the treatment of the case reported by him, extreme flexion; 
but both Physick and Fahnestock placed the arm at right angles, and 
Sir Astley Cooper lias recommended the same position. The latter posi- 
tion has always the advantage in case permanent anchylosis occurs, and 
the former cannot add much to the chance of complete replacement of 
the fragment. 

Bandages are only serviceable to retain the splint in place, and they 
may bo Thrown aside a- soon ;i- the splint is removed. 

S 3. Shaft of the Ulna. 

Causes. — The -haft of the ulna, when it alone is the seat of fracture, 
i- generally broken by ;i direct blow. I have never seen an exception 
to this rule: but Voison related in the Gazette Midicale for 1833 a 



376 



FRACTURES OF THE ULNA. 



single exception, in which it was said to have been broken by a fall upon 
the palm of the hand. Malgaigne thinks it is most often broken when 
one seeks to ward off a blow with the arm; but it has happened most 
often to me to see it broken by a fall upon the side of the arm. 

Point of Fracture, Direction of Displacement, etc. — In an analysis of 
thirty-six eases. I find the shaft has been broken eleven times in its 
upper third, fourteen times in its middle third, and ten times in its lower 
third. All portions seem, therefore, to be about equally liable to frac- 
ture. 1 think, also, the fractures have generally been oblique. 

Contrary to what has been observed by other writers, I have noticed 
that no law prevailed as to the direction in which the fragments have 
become displaced; the broken ends being found directed forwards, back- 
wards inwards, or outwards, according to the direction of the blow 
which lias occasioned the fracture; and this is in accordance with the 
general rule in other fractures occasioned by direct blows. No doubt, 
however, other things being equal, the tendency of the lower fragment 
would be toward the interosseous space, in consequence of the action of 
the pronator quadratus in this direction; while the upper fragment, 
owing to its broad and firm articulation at the elbow-joint, can only be 
displaced forwards or backwards, at least to any great extent. 

Complications. — In no case of the shaft of a long bone have I found 
serious complications more frequent than in fractures of the shaft of the 
ulna. Four have been compound; twelve complicated with a forward, 
or forward and outward dislocation of the head of the radius; one w T ith 
a partial dislocation of the lower end of the radius backwards; and one 
with a dislocation of both radius and ulna backwards at the elbow-joint. 
It will be seen, therefore, that eighteen, or nearly one-half 
Fig. 118. f the whole number, have been seriously complicated. 

Symptoms. — Occasionally this fracture is found to exist 
without sensible displacement. In such cases the diagnosis 
is -ometimes difficult, and can only be determined by the 
crepitus and mobility. If, however, the ulna is firmly 
seized above and below the point which has suffered con- 
tusion, and pressed in opposite directions, these signs will 
generally be sufficiently manifest, and will render the 
diagnosis certain. 

But in cases where there is considerable displacement, 
the inner margin of the bone is so superficial as to enable 
us to detect its deviations with the eye alone, or, when 
swelling has already occurred, by the fingers carried firmly 
and slowly along this margin. 

If the head of the radius is dislocated also, the displace- 
ment of the broken ends of the ulna must always be con- 
siderable, and the consequent deformity palpable. I have 
known one instance, however, in which a surgeon living in 
the neighboring province of Upper Canada recognized 
and reduced a dislocation of the radius and ulna back- 
wards, but did not detect a fracture of the ulna two 
Fractureofthe inches ab«»ve its lower end. Six months after, in the 
•haft of the ulna, month of March, 1856, the patient called upon me with 



SHAFT OF THE ULNA. 377 

a marked deformity near the wrist, occasioned by the backward projec- 
tion of the broken ulna, and with a complete loss of the power of 
supination. It will not surprise us that this fracture was overlooked 
when we learn that the man had fallen fifty-five feet. 

Prognosis. — In simple fractures the prognosis is generally favorable, 
since no overlapping can occur, and the lateral displacements are not 
usually sufficient to produce a marked deformity, or to interfere mate- 
rially with the functions of the arm ; yet it is not unfrequent to find the 
fragments inclining slightly forwards or backwards, inwards or outwards. 
If the fragments fall toward the radius, I have noticed in three or four 
instances a slight projection of the lower end or styloid process of the 
ulna to the ulnar side; but not interfering in any degree with the motions 
of the wrist-joint. 

I have seen a dislocation of the head of the radius left unreduced nine 
times after a fracture of the ulna, and in each example the forearm was 
shortened. A boy, aet. IT, was struck by a locomotive, and severely 
injured in various parts of his body, June 5, 1855. I saw him, with 
two very intelligent country practitioners, a few hours after the accident. 
The whole left arm was then greatly swollen. Crepitus was distinct, 
and we easily recognized the fracture of the ulna about three inches 
below its upper end, with which an open wound was in direct communi- 
cation. "We suspected, also, a dislocation of the head of the radius 
forwards, but as we could not make ourselves certain, and finding that 
the arm was in such a condition as to preclude any further manipulation 
without greatly diminishing the chance of saving the limb, we made no 
attempt at reduction, but laid the arm upon a pillow and directed cool 
water lotions. 

At no subsequent period, in the opinion of the medical gentleman 
who was left in charge, did a favorable opportunity occur to reduce the 
radius; and at the end of two months I found the ulna united, with the 
fragments bent forwards and outwards toward the radius, while the 
head of the radius lay in front of the humerus. The forearm was 
shortened three-quarters of an inch. He could flex his arm freely to a 
right angle and a little beyond; and he could straighten it perfectly. 
Hand slightly pronated, with partial loss of supination. Whole arm 
nearly ;i- strong and as useful as before the accident. 

The second case occurred in the person of a man set. 26, residing 
about twenty miles from town, and was occasioned by the kick of a 
horse. This was also ;i compound fracture It does not appear that 
hi- surgeon discovered the dislocation of the radius, but supposed that 
it was a fracture of both bones. On the ninth day the patient became 
dissatisfied and dismissed hi- surgeon, but employed no other. 

o<-r. 1. 1849, eleven weeks after the accident, he called upon me. I 
found the alna united, with ;i manifest displacement, but J could not 

discover tint there had been any fracture of the radius. The head of 

the radius was in front of the external condyle, and ;i depression existed 
where it formerly articulated. When the arm was flexed, the head did 
not strike the humerus so ;i- to arresl the flexion, but it glided upwards 
and outwards along the inclined base of the external condyle. He had 



FRACTURES OF THE ULNA. 

already begun to use his arm considerably in labor. The forearm was 
shortened one inch. 

Three times 1 have noticed after the lapse of several years that the 
forearm could not be perfectly supinated; but pronation was never 
permanently impaired. I think, also, that the motions of flexion and 
extension have always, except where the radius has remained dislocated, 
been completely restored soon after the splints were removed; and even in 
these latter cases it is only extreme flexion which has been hindered. 

I have occasionally met with examples in which this bone has failed 
to unite, and Muhlenberg, in his tables, records sixteen cases. 

Treatment — In simple fracture we must look carefully to the lateral 
deviation of the fragments; and if they are found to be salient forwards 
or backwards, pressure made directly upon or near their extremities 
restores tliem to place, but it often requires considerable force to accom- 
plish this. A gentleman fell and broke the right ulna near its middle. 
He came immediately to me, and I found the fragments displaced back- 
wards. Pressing strongly with my fingers they sprung forwards with a 
distinct crepitus, and I thought they were now in exact line. A broad 
and ^ell-padded splint was applied to the forearm, and I took especial 
pains with compresses nicely adjusted, from day to day, to keep every- 
thing in place. The arm was placed in a sling. Eight months after 
the accident this gentleman died of cholera, and I was permitted to 
dissect the arm. I found the fragments well united, but with a very 
palpable projection of the fragments backwards, in the direction in 
which they were at first. 

If the displacement is in the direction of the radius, it is more diffi- 
cult to overcome, but its necessity is much more urgent, since, if the 
fragments fall completely against the radius, a bony union may take 
place, occasioning a complete loss of the power of pronation and of 
supination. 

AVhile moderate extension is being made, and the hand is well supi- 
nated. the fingers of the surgeon should be pressed firmly, and in spite 
sometimes of the complaints of the patient, between the radius and 
ulna, and the fragments of the broken ulna fairly pushed out from the 
radius. 

'Die forearm may now be laid in the usual position against the front 
of the chest, midway between supination and pronation, and the same 
splints applied and in the manner which we shall hereafter describe for 
fracture- of the shaft of both bones. 

We ought, however, especially to bear in mind the danger of push- 
ing the fragments toward the radius, by allowing the sling or the 
bandage to rest against the middle of the ulnar side of the bone. To 
prevent this the sling ought to support the arm by passing only under 
the hand and wrist, or the forearm may be laid in a firm gutter, which 
will touch the forearm only at the elbow and wrist, or it may be laid 
upon its back, as suggested ami practised by Scott, and also by Fleury, 
the latter of whom, according to Malgaigne, bad a case which had been 
treated in the position of semi-pronation, and which remained not only 
displaced, but refused to unite: but when the arm was supinated, the 
fragments came at once into contact, and bony union speedily took 



SHAFT OF THE ULNA. 379 

place. This position may be adopted whenever it is found to be prac- 
ticable; but the position of semi-pronation is generally much more 
comfortable to the patient, at least when the forearm is laid across the 
chest, and I have found very few patients who would submit to a position 
of complete supination. 

In fractures accompanied with dislocations of the head of the radius 
forwards or backwards, nothing should prevent the immediate reduction 
of the dislocation but a demonstration of its impossibility, or a condition 
of the limb which would render manipulation hazardous. It can be 
reduced, generally, by pushing forcibly upon the head of the bone in 
the direction of the socket, while the arm is moderately flexed so as to 
relax the biceps, and while extension is being made at the forearm by 
an assistant. In making the counter-extension, care should be taken to 
seize the lower end of the humerus by the condyles, rather than by its 
anterior aspect, by which precaution we shall avoid pressing upon and 
rendering tense the tendon of the biceps. 

July 29. 1845. a lad. set. 9. fell from his bed. breaking the ulna and 
dislocating the head of the radius. Dr. Austin Flint was called on the 
following morning, and at his request I was invited to see the patient 
with him. We found the ulna broken obliquely near its middle, and 
the head of the radius dislocated forwards. While Dr. Flint seized the 
elbow in front of the condyles, I made extension from the hand, the 
forearm being slightly flexed upon the arm, and at the same moment I 
pushed forcibly the head of the radius back to its socket. The reduction 
was accomplished easily and completely. 

We then dressed the arm with an angular splint, constructed with a 
joint opposite the elbow. This was laid upon the palmar surface, and 
the whole was nicely padded, especially in front of the head of the 
radius. In two weeks pasteboard was substituted for the angular splint. 
At the end of six weeks I was permitted to examine the arm. and found 
the head of the radius perfectly in place, but the points of fracture 
slightly salient. All of the motions of the arm were fully restored. 

June 2. 1845. C. C. set. 9. fell upon his arm, breaking the ulna 
obliquely near its middle, and dislocating the head of the radius for- 
wards. Dr. J. P. White being called, requested me to visit the patient 
with him. We found one of the broken fragments protruding through 
the -kin. on the inside of the arm. 

A\ itli great ease, and by simply pressing with considerable force upon 
the head of the radius, it was made to slide into its socket. The case 
R in charge of Dr. White. 

Five week- after, I found all of the motions of the forearm completely 
ed, except that he could not extend it perfectly. The head of the 
radios was also a little more prominent in front than in the opposite 
arm. 

Four or five years later, the projection of the head of the radius had 
disappeared, and the functions of the arm were perfect. 

In Dr. Muhlenberg's tables of delayed and non-union, resection was 
practised three times, but with no recorded cures. This is a result 
which might reasonably : ted; while drilling was practised six 

-. with five suca - 



380 FRACTUBES OF THE RADIUS AND ULNA. 



§ 4. Fracture of the Styloid Process of the Ulna. 

The occasional complication of a Colles's fracture with a fracture of 
the styloid process of the ulna has already been noticed. Much more 
rarely this process is broken alone, as a result of direct violence. 

I am unable to speak of the symptoms or treatment of this accident 
farther than to say, that it must be easily recognized by its mobility, and 
probably by the presence of crepitus; and that its treatment demands 
immobilization, while the wrist is maintained in a straight position, or in 
a position slightly inclined towards the ulna. At least a fibrous union 
ought thus to be easily obtained. 



CHAPTER XXIV. 

FRACTURES OF THE RADIUS AND ULNA. 

Causes. — In a majority of the examples of this fracture seen by me, 
which have been of such a character as to warrant an attempt to save 
the limb, the accident has been occasioned by a fall upon the palm of the 
hand while the arm was extended in front of the body. Yet this cause 
is not so constant as in fractures of the radius alone, since a considerable 
number have been occasioned by direct blows ; and if we were to add to 
this estimate all of those bad compound fractures which have demanded 
immediate amputation, the proportion of fractures occasioned by direct 
and indirect blows might be found to be pretty nearly balanced. 

Point of Fracture, Character, Direction of Displacement, etc. — In a 
record of seventy-two fractures of both bones, not including gunshot 

Fig. 119. 



Fracture in the middle third. 

fracture-, or those demanding immediate amputation, I have found six 
broken in the upper third, thirty-one in the middle third, and thirty-five 
in the lower third. 

In one case the radius was broken three-quarters of an' inch above 
its lower end, and the ulna about one inch below the coronoid process. 
Four of the fractures belonging to the lower third were probably epi- 
physeal separations. 

Fifty-eight were Bimple, eight compound, one was comminuted, three 
both compound and comminuted, one complicated with a fracture of the 
humerus, and one with a partial luxation of the lower end of the radius. 



FRACTURES OF THE RADIUS AXD ULNA. 



381 



Fig. 121. 



With three exceptions, all of these more serious accidents were arranged 
among fractures of the lower third, and generally the hones had been 
broken near the wrist. 

Partial, or "green-stick." fractures have been frequently observed in 
children, but having treated of these accidents fully in the general chapter 
on Incomplete Fractures. I shall not think it necessary to make any- 
further allusion to them in this place. 

Prognosis. — Generally these bones unite in from twenty to thirty 
days : but I have seen the union occasionally delayed considerably 
beyond this time, and this delay has occurred especially in the case of 
the radius. Thus, in three cases of compound and comminuted fracture, 
the ulna united within four or five weeks, while the radius did not unite 
until the ninth or tenth week. Twice in simple fractures the ulna has 
united in the usual time, but the radius not until the sixteenth week. 
Once the ulna has united promptly and the radius remained ununited at 
the end of two years, at which time I practised resection of the broken 
ends of the radius, and union was speedily established. 

On the other hand, I have once seen the union delayed four months 
in the case of the ulna, when the radius had united in the usual time; 
and in one example of compound fracture both bones refused to unite 
until after the fifth month. Muhlen- 
berg has recorded thirty-seven cases Tig. 120. 
of delayed and non-union of both 
bones, out of a total of six hundred 
and fifty-six similar examples in all 
the long bones. 

A majority of the whole number 
seen by me have united without any 
appreciable deformity, and fifteen are 
known to have left some marked de- 
fect, while two have resulted finally 
in the loss of the arm. Of the remain- 
der I cannot speak positively. 

I have seen the fragments deviate 
Blightly in almost every direction, but 
]ii<^r ..t't«ii it lias been noticed that the 
deviation was to the radial or ulnar 
Thus, in three examples, two 
of which had been compound fractures, 
the bones have united in >uch a position 
as that from the point of fracture 
downwards the forearm has been de- 
flected to the ulnar Bide, and a marked Fracture in the 

projection has been left at the seat of lower third. 

fracture on the radial ride; while in 

two examples, both of which were simple fractures, exactly the opposite 

condition has obtained, the Lower part of the forearm being deflected to 

the radial side. 

In most cases the hand ha- been left with some tendency t<> pronation; 
in many instances this tendency was very slight and scarcely appreciable, 





. i 



J 



V 



/ 



Union with slight lat- 
eral displacement. 



382 FBACTURES OF THE RADIUS AXD ULNA. 

but in others it lias been quite marked, so that the patients have been 
wholly unable to supine the forearm except by a motion of the humerus 
in its socket. 

From what lias been said, it must be seen that the prognosis in these 
accidents takes the widest range; for while a larger proportion than in 
the case of almost any other of the long bones, unite without any ap- 
preciable deformity, a considerable number delay to unite, or do not 
unite at all, and some, even where the fracture is most simple, result in the 
complete loss of the limb. I am not now speaking of those more severe 
accidents in which the limb is at once condemned to amputation, and 
which, in the case of the arm, are numerous; but, as I have already 
mentioned, our observations here apply only to cases which came under 
treatment with a view especially to the fracture. 

I shall state the facts more fully, and then perhaps we shall think it 
proper to inquire why, when, as a rule, the treatment is found to be so 
simple and successful, occasionally, and pretty often indeed, it results 
so disastrously. 

A boy, aged about ten years, fell from a tree, April 22, 1856, frac- 
turing the right forearm near the lower end of the middle third. It 
was evident that he had fallen upon the palm of his hand, as the lower 
fragments were inclined backwards, and one of the bones had been 
thrust through the skin on the front of the arm. 

It was at first dressed carefully by Dr. Wilcox, but the father of the 
lad, on the following day, placed him under the care of an empiric. 

Six days after the fracture occurred I was called to see him, with 
several other gentlemen. He was then suffering under a severe attack 
of tetanus which had commenced the night before. His arm was much 
swollen and very painful. He died the same evening. 

I was unable to learn very particularly w T hat had been the treatment 
since the patient was seen by Dr. Wilcox, except that the bandages had 
been most of the time very tight, and that the empiric had applied 
stimulating liniments, the boy constantly complaining greatly of the 
pain. I found the arm done up in a most slovenly manner with several 
narrow splints, underlaid with loose and knotty fragments of cotton- 
batting. 

We removed all of these immediately, and laid the arm upon a cushion 
supported by a board, to both of which the arm was lightly secured by 
a few turns of a bandage; cool water lotions were diligently applied, 
and chloroform administered by inhalation; but the fatal event was 
delayed only a few hours. 

I shall not stop to inquire the cause of a result so unfortunate, where 
the treatment has been so palpably unskilful. 

I have already mentioned one case of gangrene of the hand, after a 
fracture of the lower part of the humerus. Norris, in a note to the 
American edition of Liston's Surgery, mentions a case which came 
under his observation in the Pennsylvania Hospital, the fracture having 
taken place just above the condyles; and still another has been related 
to me lately. I have brought together also no less than six cases of 
sloughing of the arm, after fracture of the radius, and one of sloughing 



FRACTURES OF THE RADIUS AND ULNA. 383 

from tight bandaging, where the radius was supposed to be broken, 
although the dissection proves that it was not. 

Robert Smith says that similar cases have been recorded in the Gazette 
Medicale. To these I shall now add eight examples of sloughing after 
fracture of both radius and ulna ; making a total of eighteen cases in the 
upper extremities, in addition to those reported in the G-azette Medicale, 
an exact account of which I have not seen. 

John MeGrath, net. 9, fell, July 2, 1847, from a ladder, about thirty 
feet to the ground, breaking the right radius and ulna in their middle 
thirds. A surgeon was in attendance about four or five hours after 
the accident occurred. He then reduced the fractures and applied two 
broad splints, one on the palmar and one on the dorsal surface of the 
forearm. Whether a roller was first applied to the arm or not, I am 
unable to say. The splints were secured in place by a roller and the 
arm laid in a sling. 

The third day was our national holiday, and the patient was not 
visited. Nor was he seen on the fourth day, not being found at home. 
On the fifth day the surgeon removed the bandages and found the arm 
gangrenous; and within an hour afterwards I was requested to see it 
also. 

I found him lying in a miserable apartment, with his right arm 
resting upon a pillow. The arm, forearm, and hand were gangrenous 
through their whole extent; and the skin of the right side, on the 
front of the chest, had assumed a dusky color, the extreme margin of 
which was indicated by an abrupt crescentic line. The thumb and 
fingers were black. His countenance was bright and cheerful, and his 
mind intelligent; pulse 75, and soft; tongue clean. He had slept un- 
disturbed the night before, and he had all along felt perfectly well, 
except that he had a slight diarrhoea. I was assured by the surgeon, 
and by all of the family, that the bandages had not been applied 
tightly ; but we were told that on the third day of the accident, having 
been locked into the house by his mother, who was a peddler, he 
climbed out of the window; and that during all of that and most of 
the following day he was running about the streets firing crackers, 
during most of which time his arm was removed from the sling and 
hanging by hid side. On the morning of the fourth day his mother 
noticed thaf his fingers were black, but she thought they were stained 
with powder. 

W e ordered liini to take one-quarter of a grain of opium every four 
hours, and applied a yeast poultice to the arm. On the seventh day 
the gangrene was still extending, and the pulse was 125; yet he con- 
tinued to feel well and to eat as usual. On the tenth day the line of 
demarcation had commenced opposite the shoulder-joint; and the cres- 
centic discoloration on the breast, which had at first spread rapidly until 
it covered nearly the whole upper half of the chest, was quite faint, in 
some parts almost l<>-t. 

In a few days more he was removed to the county almshouse, the 
separation continuing rapidly to take place until the arm fell off at the 
shoulder-joint: after which In- made a good recovery. 

A child, two years and three months old, had fallen from a chair 



384 FRACTURES OF THE RADIUS AND ULNA. 

upon the floor, a distance of aboul two feet. A German physician 
being called, found, as he believed, a fracture of both bones of the left 
arm. The fracture was Dear the middle. He immediately applied a 
roller from the Angers to the elbow, and over this three narrow splints 
made of the wood of a cigar-box. One of these was laid upon the 
palmar, one upon the dorsal, and one upon the radial side of the fore- 
arm, and the whole were bound together by another roller. From this 
time until the tenth day the child continued to play about on the floor. 
Ten days after the accident occurred the doctor noticed that tne ulnar 
side of the little finger was blue. The bandages were immediately re- 
moved, and were never again applied tightly. 

Three or four days after, I was requested to see the arm with the 
attending physician. The gangrene had continued to extend, involving 
now the whole of the little finger and most of the thumb. There were 
also gangrenous spots over the hand and forearm, extending to within 
one inch from the elbow-joint; these spots were more numerous in front 
and on the back of the forearm, and seemed to correspond to the pres- 
sure of the splints. The hand was much swollen, and also the arm 
above the line of the gangrene. The sloughs had already commenced 
to be thrown off, and the gangrene was only extending in a few points. 
The child appeared well and rather playful, except when the arm was 
being dressed. I ordered a yeast poultice, and a nourishing diet. 

I have since learned that the arm and a large portion of the hand were 
finally saved 

About the year 1865, as near as I can remember, a lad aged about 
nine years was brought to the Long Island College Hospital Dispensary, 
with a fracture of the radius and ulna. It was dressed by the visiting 
surgeon with splints and bandages. He did not return to the Dispensary 
as directed to do, and on the third or fourth day portions of the arm and 
hand were found in a gangrenous condition. 

In March, 1867, I Avas consulted by the parents of D. C, of Catta- 
raugus Co., N. Y., on account of a serious distortion of the hand and 
forearm, caused by sloughing, splints and bandages having been applied 
by her surgeon for a supposed fracture; but when examined by me, 
about ten weeks after the accident, there was no evidence that the bones 
had ever been broken. She complained to her surgeon that the bandages 
were too tight, but he thought otherwise, and they were not removed 
until the third day, when the gangrene had already occurred. The 
child was five years old at the time of the accident. 

A young man, set. 20, suffered a simple fracture of the right radius 
and ulna March 14, 1874. On the same day it was dressed with a 
roller next to the skin and over this the splints. On the following day 
the fingers woe black, but the same dressings were continued, and they 
were not removed completely until the next day. He was admitted to 
Bellevue on the 16th, and, by courtesy of Dr. Gouley I was permitted to 
examine the arm on the 7th of April. He had then lost all of his 
fingers, except a portion of the thumb, and there were extensive slough- 
ing and suppuration along the forearm. His condition was very critical. 
His death took place a few days later. It is worthy of remark that, 



FRACTURES OF THE RADIUS AND ULNA. 385 

after the first few hours, there was no pain in the arm, although the 
dressing had not been removed. 1 

Alice Thompson, set. 50, fell upon her left hand in March, 1870, caus- 
ing a compound fracture of the radius and ulna, about three inches above 
the wrist-joint. She went at once to one of the New York City Dispen- 
saries, and the surgeon dressed the arm with splints, applying the band- 
ages "snugly." Two days later she was brought to one of my wards at 
Bellevue, with the back of the hand and most of the forearm in a state 
of gangrene, evidently caused by the bandages. Seven or eight days 
later she died before the house surgeon could reach her, from a second- 
ary hemorrhage. 

In the following case there was probably no fracture; no doubt could 
be entertained, therefore, as to the cause of the gangrene : 

A girl, ?et. 5, fell upon the palm of her hand in 1866. A surgeon 
saw her within one hour, put on two wooden splints, with cotton-batting 
laid loosely underneath, securing them with a roller. Half an hour after 
it was dressed the fingers were blue, and the pain was so great that the 
surgeon was recalled. On his arrival he said it was not too tight. On 
the following day the condition was the same, but the surgeon refused to 
loosen the dressings. Two days later he removed the bandage, and 
found a slough extending nearly the whole length of the palmar surface 
of the forearm. Some months later I found the arm straight, but the 
hand much distorted by the cicatrix. 

I have now to relate a case in which sloughing and death occurred as 
the consequence of a tight bandage, the patient being under my own 
charge : 

James Brachen, get. 22, was admitted to ward 12, Bellevue Hospital, 
April 1, 1871, with a fracture of the left forearm, near its middle, caused 
by the kick of a horse on the day before. On the same day I dressed 
the fracture before the class of medical students in the hospital, using a 
palmar and dorsal board splint, covered and stuffed with cotton-batting, 
according to my usual method; securing the splints with a roller, includ- 
ing the hand and forearm. The arm was then placed in a sling and he 
was -cut to his ward. The following day being Sunday, I did not visit 
the hospital. On Monday I inquired for him, and learned that he was 
out walking in the yard. Tuesday I met him, returning from a walk' in 
the yard, just as I was leaving the ward. He was apparently in perfect 
health, but. as I stopped him a moment to look at his arm, I saw that the 
hand was swollen and purple. The dressings were immediately removed, 
and the patient placed in bed. There were upon the arm two spots look- 
ing like superficial sloughs. He was suffering no pain. The gangrene 
subsequently extended until it involved a large portion of the hand and 
forearm, and on the eighteenth day after the receipt of the injury he 
died. 

I will submit the case without comment, except to say that a careful 
and daily observation of the condition of the hand, and a prompt removal 
or loosening of the dressings when the hand first showed symptoms of 
arrest of circulation, would probably have prevented this disastrous re- 

1 Now York Journ. Med., June, 1874. 
25 



386 FRACTURES OF THE RADIUS AND ULNA. 

suit. The splints and bandages were removed the first time I saw him 
after the original dressings had been made, but this was too late; some 
one should have seen the approaching cloud and before it was ready to 
burst. 

South also says that he has seen one or two instances of mortification 
produced by splints applied too tightly, and previous to the accession of 
the swelling after fracture, and which had not been loosened as the swell- 
ing increased. 1 

How shall we explain the frequency of these accidents after fracture, 
especially of the forearm ? 

Malgaigne, speaking of fractures of both bones of the forearm, re- 
marks that "when the 'displacement is considerable, or more especially 
when the outward violence has been excessive, we frequently see follow 
a very intense inflammatory swelling, and there is no fracture which com- 
plicates itself so easily with gangrene under the pressure of apparatus." 2 

Says Nelaton: "If we make choice of the apparatus of J. L. Petit, 
it is necessary that it shall not be applied too tightly, for, as Professor 
Roux has long since remarked, fractures of the forearm are those which 
furnish most of the examples of gangrene in consequence of an arrest 
of the circulation. This is easily understood, if we consider on the one 
hand the superficial position of the two principal arteries of the forearm, 
and on the other the disposition of the apparel, which must almost in- 
fallibly compress the arteries to a great extent." 3 

I do not think that this accident is due always to the negligence of 
the surgeon. It may be due many times to the carelessness of the parents 
or of the patient himself; as in the case of the boy who came under my 
own observation, and who lost his arm at the shoulder-joint. Sometimes 
also it may be due rather to the severity of the original injury, which, 
the experience of every surgeon will prove, is occasionally competent to 
the production of such bad results. A number of unfortunate circum- 
stances may have concurred, such as a severe injury, especially where 
the skin has remained unbroken and the effused blood has had no oppor- 
tunity to escape — the broken bone may have rested against the trunk of 
a main artery, causing an arrest of its circulation — the constitution may 
be impaired by previous illness, or it may be suffering under the shock 
of the injury ; yet that it may be and too often is the result of maltreat- 
ment on the part of the surgeon, is undeniable. It is proper, however, 
to discriminate between the responsibility which attaches to the surgeon 
as the true exponent of the state of his art, and that which attaches to 
the art itself as taught by the masters. 

The old surgeons applied first a roller to the hand and forearm, and 
over this their various splints. J. L. Petit thought he had made a valu- 
able improvement upon this simple plan, by laying over the roller a 
compress and splint ; the compress being intended to press between the 
bones, and to antagonize the action of the roller in drawing the fragments 
toward each other. Duverney believed that this object would be best 
accomplished by placing the pad against the skin, and under a circular 

1 South, note to Chelius's Surg., vol. i. p. 69. 
' Malgaigne, Frac. et Disloc.,"tom. i. p. 589. 
3 Nelaton, Pathologie Chirurgicale, p. 735. 



FRACTURES OF THE RADIUS AND ULNA. 387 

compress ; while Desault declared all of these modes inefficient, and 
announced a method which he regarded as accomplishing at once and 
completely all of the indications ; the sole peculiarity of which method 
consisted in placing graduated pads against the skin, and securing them 
in place by a roller. Boyer adopted the same method without any 
modifications, and Mr. Hind, in his illustrations of fractures, already 
referred to, has seen fit to recommend the same, at least in fractures of 
the radius. 

It is quite obvious that between these various methods there remains 
very little if anything to choose, the differences being too trifling and 
unessential to claim serious consideration. Each alike is inadequate to 
accomplish any amount of useful pressure between the fragments ; each 
alike is calculated to bind the bones one against the other, and each alike 
exposes to the danger of ligation and of gangrene. 

Says M. Dupuytren : " The practice of rolling the arm before the 
splints are applied, whether internal or external to the pads and com- 
presses, is eminently mischievous ; and instead of fulfilling, directly 
counteracts the indications which it is most important to keep in view 
in the treatment of fractures of the forearm." 

And notwithstanding the same sentiment has been reiterated by Vel- 
peau, Malgaigne, Nelaton, Samuel Cooper, Bransby Cooper, Erichsen, 
Amesbury, Gibson, and others, yet we find the great surgeon of Heidel- 
berg. Chelius, recommending the roller to be applied under the splints, 
after the manner of Desault ; while Liston, Syme, and Fergusson, who 
perhaps represent the Edinburgh school, use only pasteboard splints 
above the compresses, over which is immediately applied the roller; a 
practice which differs very little from that recommended by Desault, and 
is equally obnoxious to criticism. 

Among the American surgeons, I believe, the advice and practice of 
Dupuytren have received almost universal assent, only that we have 
always employed splints much wider than those recommended by this 
<li.-tin<_niished surgeon. I cannot therefore agree with my accomplished 
countryman, Dr. Reynell Coates, if in the following paragraph he means 
to imply that American surgeons generally adopt Desault's treatment. 
Such at least is not my experience. "It would be wrong," says Dr. 
Coates, "not to bear testimony, on every possible occasion, against the 
folly so universally prevalent, that induces surgeons to apply a bandage 
directly to the forearm before applying splints in injuries of this char- 
aeter. We have often asked for a rational explanation of this practice, 
without effect. It is directly at war with the acknowledged indications 
in the coaptation of the fragments, and when the object of the whole 
apparatus is to thrust asunder their extremities, it commences by bind- 
ing them together. Few plans in surgery are more generally followed ; 
none c;in be more absurd." 

Of the estimate placed upon the roller by M. Mayor, the reader will 
judge by ;i reference to the passage which J shall quote farther on, when 
I -hull speak of the value of the* interosseous compresses. 

Amesbury and Bransby Cooper use no rollers at all — not even to 
secure the splints in place, they being made fast to the forearm by straps 
or tapes. 



388 FRACTURES OF THE RADIUS AND ULNA. 

Mr. Amesbury and Mr. South also endeavor to give to their splints 
an appropriate shape, by having them constructed with more or less 
convexity. It must be noticed, however, that the practice of these two 
gentlemen is vow dissimilar, for while Mr. South applies the convex 
surface of his splint to the interosseous space, Mr. Amesbury reverses 
this plan, and applies the concave surface directly to the skin. 

As to the width of the splints, surgeons are also very generally 
agreed, at the present day, that they ought to be wider than the arm, 
so as to prevent the roller or the tapes from resting against its sides. 

I do not intend to deny peremptorily, and without qualification, the 
value of the graduated compresses, which, as we have seen, are usually 
laid along the interosseous space to press the fragments asunder. It is 
necessary, however, to caution the surgeon against their injudicious use. 
M. Nelaton has well remarked of the apparel employed by J. L. Petit, 
that it must inevitably compress, to a great extent, the arteries of the 
forearm ; and the remark is applicable, in only a less degree, to all of 
those other plans in which the compress is employed. And I suspect 
that to this portion of the dressing, quite as much as to any other cause, 
are due those frightful accidents of which we have already spoken. 
The arteries are not only exposed, from their superficial position, to 
pressure from a compress, but, in addition to this, it will be noticed 
that the two principal arteries, the radial and the ulnar, are situated 
upon a broad and flat surface of bone, along which this pressure must 
operate most advantageously. So early as the year 1833, M. Lenoir, 
in his inaugural thesis at Paris, called attention to this danger, and 
from time to time surgeons have continued to advert to it, but they 
have seldom given to its consideration that prominence which its im- 
portance deserves. 

I have observed another fact in this connection : when this compress 
is extended low down on the palmar surface, within an inch or two of 
the wrist-joint, it soon becomes excessively painful, and sometimes even 
wholly insupportable, in consequence of the pressure made upon the 
median nerve ; and I find myself always obliged to exercise great care 
in the adaptation of the pads at this point. For this reason alone, I 
believe, in case of a fracture near the base of the radius, the lower 
fragment, if it were thrown toward the ulna, could not be retained in its 
place by graduated compresses. 

In short, finding that broad splints, properly covered and padded, 
answer very well to crowd the muscles into the interosseous space, so 
far as it is proper to do so, and believing that this mode is less painful 
and less dangerous, I never resort to graduated compresses, nor can I 
appreciate their necessity, or, indeed,, their utility. Mr. Lonsdale also 
concurs with me in attaching very little value to this part of the accus- 
tomed apparel. 

But listen to the surgeon of Lausanne, M. Mayor: "What signify 
graduated compresses placed between the bones of the forearm for the 
purpose of separating them from each other? These bones will not 
have that constant tendency to approach each other which has been 
supposed, provided, first, that they have been well reduced ; second, 
that for the purpose of maintaining them in position we do not make 



FRACTURES OF THE RADIUS AND ULNA. 389 

use of a preliminary circular bandage, whose action is an absurdity; and, 
in short, provided we make the retentive means act chiefly upon the 
palmar and dorsal surfaces of the forearm." 1 

M. Mayor proceeds to declare these convictions to be the result of his 
own experience, both in the treatment of simple and compound fractures 
of the forearm, and he intimates that in the use of the circular bandage 
with compresses, surgeons seem to have rolled the arm into a cylinder 
and drawn the bones together, in order that they might tax their in- 
genuity to discover some means to again separate them. 

Surgeons have generally, after the splints have been applied, placed 
the forearm in a position of semi-pronation, or midway between supina- 
tion and pronation, so that the radius should be uppermost; it being 
assumed that in this position the two bones are most nearly parallel, and 
least inclined to displacement. Such, indeed, was the practice of Hip- 
pocrates, Paulus iEgineta, Celsus, Albucasis, and of most surgeons down 
to this day; but Lonsdale, Robert Smith, Nelaton, and South have 
lately called in question the correctness of this mode of dressing, at least 
when it is adopted as a universal rule. 

I have before mentioned, when treating of fractures of the ulna, that 
M. Fleury had, in one instance, been unable to bring the fragments into 
apposition except by forced supination of the forearm ; and in certain 
fractures we have seen the same position recommended by Lonsdale. 

Says Mr. South, in a note to Chelius: "In fractures of both bones 
the forearm is best laid supine;" and Nelaton declares that in fractures 
of the radius and ulna at any point of their upper thirds it will be neces- 
sary to supine the arm, both in the reduction and during the subsequent 
treatment ; but that in fractures of the inferior two-thirds we may place 
the limb in a condition of semi-pronation. 

It seems very probable, however, that both of these gentlemen have 
received their suggestions from Mr. Lonsdale, who, as we have already 
seen, lias treated the question very much at length, and who has finally 
declared his decided preference for the supine position in the treatment 
of all fractures of the forearm. His arguments are certainly very in- 
genions, and as applied to fractures of the radius above the insertion of 
the pronator radii teres, they seem altogether conclusive; and, indeed, 
they commend themselves very strongly to our judgment, as applied to 
all fractures of the forearm. They are sustained also by the results of 
Ins own experience, and I see no good reason why they should not be 
more thoroughly examined and tested by other surgeons. The advan- 
tages which he claims for this method are, more perfect coaptation of the 
broken ends, less liability of the fragments to encroach upon the interos- 
space, and consequently less danger of anchylosis between the 
bones and of Don-union of the fragments, more complete restoration of 
the power of supination, and less tendency to lateral distortion, or of 
hilling off to the ulnar or radial sides. 

My own cases, treated by the usual method, have shown that while 

1 Bandages et Appareile fl Panaements, ou Nouveau Systdme Deligation Chirur- 
gicale, par M. Matnias Mayor, Chirurg. en Chef del'Hdpital de Lausanne, Switzer- 
land. Park ed., 1838, p 846. 



390 FRACTURES OF THE RADIUS AND ULNA. 

supination is frequently impaired, and sometimes entirely lost, pronation 
is rarely affected; and that lateral displacements are much more common 
than displacements forwards or backwards. How this position, semi- 
pronation, may tend to the production of a permanent pronation, I have 
fully explained when speaking of fractures of the head of the radius ; 
and in the influence of the same position, the forearm resting upon its 
ulnar margin in the sling, in the production of a lateral deviation, is also 
easily understood. If the arm rests upon the sling so that its weight 
bears more upon the point of fracture than upon the extremities of the 
bones, then the ulna, or both ulna and radius, will incline gradually to 
the radial side, and the hand will fall off to the ulnar side; or if the 
sling rests under the wrist or hand chiefly, the hand will ascend to the 
radial side, and the broken ends of the two bones will project to the 
ulnar side. 

If this plan be adopted, viz., laying the hand and forearm upon its 
back, instead of upon its ulnar margin, the elbow should remain at the 
side, the humerus falling perpendicularly from its socket; and the fore- 
arm should rest in the sling directed forwards from the body. 

The following is the method usually employed by the author: 

Two thin, but firm, wooden splints are prepared, of uniform breadth, 
sufficiently wide that when the roller is applied it shall touch only lightly 

the radial and ulnar margins of the 
- FlG - 122, forearm. The palmar splint should be 

long enough to extend from the bend of 
the elbow, the arm being flexed, to the 
^j^^™^^^^^^ 3 metacarpophalangeal articulations, 
the fingers being flexed. The dorsal 
splint should be a little shorter, or of a length to extend from the base 
of the olecranon process to the carpus. Both of these splints must be 
covered with cloth, and properly padded with cotton-batting; taking 
care to leave but little of the cotton placed where it might press upon 
the radial and ulnar arteries and median nerve; that is, at the front of 
the wrist. 

The splints, being carefully fitted, are applied while the forearm is 
held at a right angle with the arm, and in a position midway between 
pronation and supination, one to the palmar and the other to the dorsal 
surface of the forearm, and secured with a roller. There must be no 
pressure against the humerus at the bend of the elbow; and the fingers 
must be flexed easily over the lower end of the palmar splint. The 
dorsal splint should not extend beyond the lower end of the radius and 
ulna. It is understood, of course, that while the splints are being 
secured in place, extension and counter-extension are maintained for the 
purpose of securing coaptation of the broken extremities as far as possi- 
ble. The dressing being completed, the forearm is suspended in a sling. 

Finally, whatever may be the mode of dressing, let me repeat the 

injunction to examine the arm frequently. No surgeon can do justice 

to himself, or to his patient, who does not look at the arm at least once 

in twenty-four hours during the first ten or fourteen days, and in some 

3 the patient ought to be seen twice daily. 

When the fracture is compound, it is often quite impossible to retain 



FRACTURES OF THE CARPAL BONES. 391 

the forearm in the half-pronated position ; since, when thus placed, and 
only slightly supported, as it must necessarily be, it inevitably falls over 
upon its palmar surface. 

There can be no doubt that in such a case we ought, from the first, if 
it is found practicable, to place it upon its back, in a position of complete 
or nearly complete supination. For this purpose, a single broad splint, 
carefully cushioned, and covered with oiled cloth, is the most suitable. 
Upon this the forearm is to be laid, and secured gently with a few turns 
of the roller. If the patient is able to do so, and wishes to walk about, 
the board may be suspended to the neck, as recommended by M. Mayor. 

I have said that we ought, in cases of compound fracture, to lay the 
forearm upon its back, if practicable. I am sure, however, that the 
surgeon will find very many patients who cannot endure this position, 
and he may be compelled, therefore, to lay the limb upon its palmar sur- 
face, or to leave it to assume any other position in which it may be the 
most at ease. In conclusion, I desire again to call attention to the splint 
employed by Dr. Scott, and of which an illustration is given in the 
chapter which treats of Fractures of the Radius. 

Recently, in a letter from Dr. G. W. Burke, of New Castle, Indiana, 
I am informed that in the case of an oblique fracture of both bones of 
the forearm, occurring in a man thirty years of age, and at the junction 
of the lower and middle third, the fragments were thrust downwards and 
outwards until they had nearly penetrated the skin. Finding, after 
repeated efforts, that he was unable to extricate them from the muscles 
and fascia which they had penetrated, he made an incision, exposed the 
bones, and replaced the fragments. The arm was subsequently dressed 
in the usual way, and he made a good recovery. Resection of the frag- 
ments was not required. The practice in this case was no doubt sound, 
inasmuch as in no other way could the bony union of the fragments have 
been assured. 

Of the 37 examples of delayed and non-union recorded by Muhlen- 
berg, 30 were subjected to treatment. Of 4 treated by manual friction, 
1 was cured and 3 failed. One treated by section was cured. Of 17 
treated by resection, 11 were cured and 6 failed ; 4 were treated by 
drilling, and all failed. Of 4 treated by mechanical appliances and 
immobilization, 2 were cured and 2 failed. 1 



CHAPTER XXV. 

FRACTURES OF THE CARPAL BONES. 

All of the cases of fracture of the carpal bones which have come under 
my observation were, without exception, compound and complicated, and 
have resulted in the complete loss of the hand, or in some less serious, 
but never inconsiderable, mutilation or maiming. 

1 Muhlenberg, Agnew's Surg., op. cit., vol. i. p. 805. 



392 FRACTURES OF THE METACARPAL BOXES. 

In do case has a treatment been adopted which might be regarded as 
having reference to the fracture, or the purpose of which was to insure 
apposition and union of the fragments. 

It may be proper to assume in a matter so easily comprehended, what 
actual and recorded experience has not proven, namely, that simple 
fractures of these hones will demand very little surgical interference, 
and that they will unite generally without much displacement, and with- 
out any considerable maiming. It is, indeed, quite probable that some 
degree of anchylosis between their adjacent surfaces will occur, yet even 
in the normal condition they enjoy so little motion as to render it doubtful 
whether its complete loss would be very sensibly felt. 

In cases of comminuted, compound, and otherwise complicated fractures 
of the carpal bones, which accidents are sufficiently common, the surgeon 
has only, I conceive, to follow carefully those general or special indica- 
tions which may happen to be present, the precise character of which it 
would be difficult to anticipate, and for the treatment of which it would 
be unsafe to attempt in a written treatise to provide. 



CHAPTER XXYI. 

FRACTURES OF THE METACARPAL BOXES. 

Development of Metacarpal Bones. — These bones are each formed 
from two centres of ossification. In the case of the metacarpal bones of 
the four fingers there is one centre for each shaft, and one for each distal 
extremity : but in the case of the metacarpal bone of the thumb there is 
one centre for the shaft and one for the proximal extremity. All these 
epiphyses unite with the shafts at about the twentieth year. 

Causes. — They are generally broken by direct blows; and in that 
case the injury is often of such a character as to demand amputation, 
and does not therefore belong to that class of accidents of which it is 
the purpose of this volume to treat. Not an inconsiderable number, 
however, are the results of indirect blows, and especially of blows upon 
the knuckles received in pugilistic encounters. Thus, in a record of 
sixteen fractures. I find this cause assigned in seven : in one other in- 
stance it was occasioned by falling upon the clenched fist, and in one bj 
striking a board : so that the fracture has resulted from a blow upon the 
ends of the bones in nine of the sixteen examples. 

Point of Fracture : Direction of Displacement ; Symptoms. — Once 
the fracture lias occurred in the metacarpal bone of the thumb ; eight 
times in the metacarpal bone of the index finger; once in the second 
finger: three time- in the ring finger, and three times in the metacarpal 
I.-, ue of the little finger. Two of those belonging to the ring finger, and 
the three occurring in the little finger, were produced by blows with the 
clenched fist, and in each instance the fracture was in the lower or distal 
third of the hone. Three of the fractures of the metacarpal bone of the 



FRACTURES OF THE METACARPAL BONES. 893 

index finger were produced also in the same way; two of which were 
near the middle of the bone, and one near the proximal end. Of the 
whole number, seven were broken through the lower third, five through 
the middle, and four through the upper third. 

In everv instance where the bone is known to have been broken by a 
blow upon the knuckles, the distal end of the distal fragment was thrown 
toward the palm, and this fragment was salient backwards at the point of 
fracture. 

In the following case the bone was probably separated at the epi- 
physis : 

Thomas Eose, aet. 8, fell down a flight of steps, September 11, 1855, 
breaking the metacarpal bone of the index finger of the right hand near 
its lower extremity, and apparently at the junction of the epiphysis with 
the diaphysis. 

I saw the lad about sixteen hours after the accident. The lower frag- 
ment, projecting abruptly into the palm of the hand, could be easily 
replaced, or with only moderate effort, yet immediately when the support 
was removed it would become displaced. There was no crepitus. 

It was dressed very carefully with a splint and compress ; but, not- 
withstanding our continued efforts to keep the fragments in place, the 
epiphysis united considerably depressed toward the palm. 

In one instance, also, I think the bone was rather bent, or partially 
fractured, than broken completely. This was the case of fracture of the 
metacarpal bone of the ring finger, produced in a gymnasium by striking 
with the clenched fist against a board, and to which I have already alluded. 
I did not see the young man until four weeks after the accident, when I 
found the lower end of the bone depressed toward the palm, and the 
angle made at the point of fracture was rather rounded and quite 
smooth : it was also tender at this point, but the bone was firm and un- 
yielding. Four years after I was permitted to examine it again, and I 
found the same slight deformity still continuing. 

A partial explanation of the fact that the distal end of the distal frag- 
ment is generally displaced toward the palm, may be found in the natural 
curve of these bones, which is such that when the fracture has been pro- 
duced by a counter-stroke, the distal end would almost necessarily be 
driven in this direction ; and a farther explanation has been suggested 
by Mr. I>. Cooper, namely, the action of the interossei. 

Hefi/Jts. — Generally, when the fracture is simple, and the displace- 
ment i- not considerable, the nature of the accident is overlooked, and 
deformity must inevitably ensue. In a majority of the cases which 

have come under my observation tin's lias been the fact, and the bone has 
remained slightly bent at the seat of fracture, but without affecting in 
any degree the value of* the hand. 

The following example has furnished the mosl serious result of any 

Case of simple fracture of these bones which lias come under my notice: 

Louis Mooney, set. 25, struck a man with bis clenched fist, November 
4. 1^~>i'k breaking the metacarpal bone of the index finger of the righl 

hand near its middle. Great swelling and suppuration followed the 
injury. 

February 21, 1 v -">7 . nearly four months after the injury was received, 



394 FRACTURES OF THE METACARPAL BONES. 

he consulted ine. There existed at this time a complete anchylosis at 
the wristrjointj and a partial anchylosis in the fingers. The hand was 
deflected forcibly to the radial side. At the point of fracture the frag- 
ments were salient backwards and quite prominent, but firmly united. 

Even when the existence of the fracture is recognized, it is not always 
easy to retain the fragments in place, as the case of epiphyseal separation 
already mentioned, and the following case will illustrate : 

Miss E., of Erie Co., N. Y., set. 18, fell, August 7, 1353, striking 
upon her right hand with her fingers forcibly bent into the palm of the 
hand. On the following day she consulted me at my office, and I found 
the metacarpal bone of the ring finger broken about three-quarters of an 
inch from its distal end, and the distal extremity of the fragment depressed 
toward the palm. A feeble crepitus, with distinct motion, completed the 
diagnosis. The young lady was very anxious to have a perfect hand, and 
I was determined if possible to accomplish it. Finding that the joint 
end of the distal fragment was constantly disposed to fall toward the 
palm, I constructed a gutta-percha splint for the hand and fingers, and 
after placing a pad directly underneath this fragment, I secured it firmly 
with a roller. From this time until the end of four weeks she remained 
under my care, visiting me as often as once or twice a week, and at 
each dressing I found the distal fragment slightly displaced in the same 
direction as at first, nor was I able ever to make it resume completely its 
position. 

Ordinarily, however, no such difficulty is experienced, and the bone, 
supported by such simple means as I shall presently direct, unites 
quickly and without deformity. 

An engineer was struck by a piece of iron in such a way as to break 
his right forearm and the second metacarpal bone of the same hand. 
The fracture of the metacarpal bone was compound and about three- 
quarters of an inch from its proximal extremity. When he called upon 
me, which was immediately after the injury was received, I found the 
proximal fragment projecting directly backwards, its sharp point rising 
above the skin, into which position it was evidently drawn by the action 
of the extensor carpi radialis longior muscle. By pressure alone it could 
be replaced, but it was much more easily reduced when the hand was 
forcibly carried backwards on the forearm. I therefore secured the hand 
in this position with appropriate splints, and it was maintained in this 
posture during most of the subsequent treatment. Union finally took 
place, but not without some backward displacement. Four months after 
the accident occurred, on the 31st of December, 1858, I examined the 
hand, and found the skin healed over completely, the end of the frag- 
ment having become rounded and smooth, so as not to give him any 
degree of annoyance. His wrist was as flexible and as strong as before. 
No doubt the projection of the fragment might have been prevented 
entirely by cutting at the point of its attachment the tendon of the 
muscle, but this would have sensibly weakened the wrist-joint, and I 
preferred the alternative of a projection of the fragment. 

Treatment. — With moderate extension made upon the finger corre- 
sponding to the broken bone, while the fragments are forced home by 
firm pressure, the bone may generally be brought at once into line, and 



FRACTURES OF THE FINGERS. S95 

we may now proceed to adapt a gutta-percha, felt, or thick pasteboard 
splint, to either the whole surface of the back or palm of the hand and 
fingers, while they are held in a position of easy flexion. It is not very 
material to which of these surfaces the splint is applied ; or rather, I 
may say. it ought to be applied to the one or the other according as cir- 
cumstances seem to indicate. It should be well padded, and especially 
at certain points, in order to the more effectual support of the fragments. 
It is then to be secured in place with several turns of a roller. When 
either of the metacarpal bones, except those of the great or ring finger, 
is broken, the splint must be wide enough to secure the sides of the hand 
against the pressure of the roller. 

Thus dressed, the hand may be laid in a sling beside the chest, or 
while sitting it may rest upon a table. 

The apparel must be examined daily, and readjusted as often as it 
shall become disarranged, or as a doubt shall arise as to the condition of 
the parts. 

When the fracture is followed by much inflammation, or occurs near, 
and especially if it actually involves a joint, the same precautions must 
be adopted to prevent anchylosis as in the case of similar fractures in 
other bones. 



CHAPTER XXVII. 

FRACTURES OF THE FINGERS. 

Development of the Phalanges of the Hand. — The phalanges of the 
hand are formed from two centres of ossification, namely, one for each 
shaft and one for each proximal end. Ossification commences in the 
shafts at about the sixth week; in the epiphyses of the first phalanges 
between the third and fourth years, and in the epiphyses of the last two 
phalanges somewhat later. Complete bony union takes place between 
the epiphyses and the shafts at from the eighteenth to the twentieth 
year. 

( '"uses. — I do not remember to have seen a fracture of one of the 
phalanges produced by a counter-stroke; I am aware, however, that 
they are occasionally produced in this way, as by falling upon the ends 
of the fingers, and especially by the stroke of a ball in the game of base. 

The fact, however, that they are generally the consequence of a direct 
blow, and that the finger bones are small and only protected by a thin 
covering of skin and tendons, renders them peculiarly liable to commi- 
nution and to other serious complications. Thus, in a record of thirty 
fractures, only eighteen were sufficiently simple to warrant an attempt 
to save them ; and only five are recorded as simple fractures without 
complications. 

Point of Fracture and Direction of Displacement. — In the following 
case there was probably an epiphyseal disjunction. A lad four years old 
was admitted to the Buffalo Hospital of the Sisters of Charity, Dec. 24, 



396 FRACTURES OF THE FINGERS. 

1849, with a simple fracture of the first phalanx of the ring finger of the 
Left hand ; the fracture being at the proximal end of the bone, and at the 
junction of the epiphysis with the shaft. 

The finger was so much swollen at first, that no dressings were applied 
until the fifth day, at which time a gutta-percha splint was moulded to 
it carefully. It resulted in a perfect cure. 

I have not seen the fragments much overlapped, except in one in- 
stance. Occasionally there has been no perceptible displacement; but 
generally there will be found a slight displacement in the direction of 
the diameter of the bone. 

The case to which I refer as presenting an extraordinary overlapping 
was that of an Irish laboring woman, aged about thirty-five years, who, 
having fallen down a flight of steps, broke the first phalanx of the thumb 
below its middle. Dr. Congar was first called on the day following the 
accident, but was unable to reduce the fracture, and on the same day 
invited me to see the patient with him. The distal- fragment was dis- 
placed backwards, overlapping the proximal fragment a little more than 
one-quarter of an inch. We made repeated efforts, by pulling upon the 
thumb with a sliding noose, and with all the strength of our four hands, 
but to no purpose. The fragments could not be reduced for one moment ; 
and we left the patient as we had found her, only somewhat the worse 
for our violent and repeated extensions and manipulations. The finger 
was already considerably swollen when we began our efforts, and we 
cannot therefore say what might have been accomplished at an earlier 
moment, but I confess that our defeat was unexpected, and does not 
seem to me to be satisfactorily explained. 

Results. — At least ten have left no appreciable lameness or deformity, 
and possibly several more. It is therefore probably true that these con- 
sequences may be avoided with proper care in one-half of the examples 
in which we attempt to save the finger ; and perhaps it will occasion 
surprise that a perfect result may not be claimed in a larger proportion ; 
but when we consider how frequently the accident is compound, and that 
even when it is not, the blow having generally been received directly 
upon the point of fracture, how promptly swelling ensues, it will be easily 
understood that it will be often found difficult to determine whether the 
bone is exactly in line or not, or to maintain it in this position after 
absolute coaptation has been once secured. 

I have seen the finger in two or three cases deviate laterally, or become 
permanently deflected to one side or the other; and once I have found 
it united, but rotated on its own axis. This latter case is not without 
instruction. 

A girl, set. 6, had her little finger caught by a door violently shut, 
breaking one of the phalanges, and nearly severing the finger. I closed 
the wound, and dressed the finger with a moulded pasteboard splint. My 
dressings were repeated often, and applied carefully; nor did I detect 
the rotation which the lower fragment had made upon its own axis until 
the union was consummated. I then found the extremity of the finger 
turned so that its palmar surface presented diagonally toward the ring 
finder. 

If the surgeon believes that this ought to have been prevented, and 



FRACTURES OF THE FINGERS. 397 

that the result evinces a lack of skill or of care, its record may still serve 
one of the purposes for which it was designed, and secure to the patient 
sometimes hereafter more faithful and assiduous attention. 

Treatment. — Boyer, and after him Bransby Cooper, have taught that 
when the extreme phalanx is broken, from the small size of the bone, 
and from its having attached to it the nail and its matrix, it is better in 
all cases to amputate at once, as the process of reparation is in such case 
extremely slow and uncertain. 

Whether in any of the cases treated by myself, or which have been 
seen by me. the fracture involved the last phalanx, I am not now able 
to say. but my impression is that such cases have come under my notice 
which have been successfully treated, and I cannot but regard the rule 
established by these gentlemen as much too stringent. Examples must, 
no doubt, sometimes occur, in which the fracture is so simple in its char- 
acter as to render prompt reunion pretty certain ; and even though the 
restoration should prove tedious, this ought scarcely to be regarded as a 
sufficient justification for so serious a mutilation as these surgeons pro- 
pose, since the loss of even an extreme phalanx is not only a deformity, 
but must prove in many occupations a troublesome maiming. 

Prof. J. Lizars, of the Toronto School of Medicine, C. W., has re- 
ported to me a case exactly in point: "A man in the employ of the 
Toronto Rolling Mills Company fractured the distal extremity of the 
ring finger of the right hand. The fracture was transverse, and the 
nail was severely bruised, the accident being caused by a direct blow. 
Crepitus distinct. A dorsal splint and bandage were applied, and in a 
short time the fragments were united firmly by bone. The nail subse- 
quently fell off, and a new one was formed." 

The rule ought still to be held inviolate, which surgeons have so often 
repeated in reference to injuries inflicted upon the hand and fingers, 
namely, that we should save always as much as possible. 

It is remarkable, too, how much nature, assisted by art, can do toward 
the accomplishment of this purpose. If the bone of a finger is not only 
severed completely, but also all of its soft coverings, save only a narrow 
band of integument, are torn asunder, a chance remains for its restora- 
tion. And it is especially interesting to observe what recuperative 
powers are possessed by the articular surfaces of these smaller joints, so 
that although they may be broken into, or sawn through, or comminuted, 
and although small fragments be entirely removed, a complete restora • 
tion of their functions is sometimes permitted. I have seen and reported 
some snch examples. It is true, however, that such fortunate results are 
rare, and they are rather to be hoped for than anticipated. 

Since, in the case of these delicate bones, the slightest deviation from 
the natural form or position determines in the end an ugly deformity, it 
becomes exceedingly necessary, especially with females, that we should 
open the dressings and examine the fingers carefully from day to day. so 
that, as the .-welling subsides, we may discover and correct any displace- 
ment which may happen to exist 

A- a splint, I have found nothing so convenient as gutta percha, 
moulded accurately to either the dorsal or palmar aspect of the finger; 
and the form of which I have found it generally necessary to change 



398 FRACTURES OF THE FINGERS. 

slightly every third or fourth day, until consolidation is nearly or quite 
completed. 

If the fracture is near or extends into a joint, the finger ought to be 
a little flexed, so as to place it in the most useful position in the event 
that anchylosis should occur; and as early as the end of the second 
week the joint surfaces should be slightly moved upon each other, in 
order to the prevention of fibrous or bony adhesions. Nor is there 

Fig. 123. 




Gutta-percha splint for finger. 

much danger of preventing the union of the bone by moving the joints 
at this early day. Union occurs between these fragments very speedily, 
and I have never met with a case of non-union of the phalanges, nor do 
I remember to have seen a case reported. 

It is the lateral inclination of the distal end of the finger which, ac- 
cording to my experience, it will be found most difficult to obviate, and 
which may, perhaps, in some cases be most successfully combated by 
laying the two adjoining sound fingers against the broken finger, and 
then applying a moulded splint to the palmar surface of the whole. In 
other cases it will be more convenient to apply the splint only to the 
broken finger. 

Rotation of the lower fragment on its own axis is especially to be 
guarded against, as the deformity which it occasions is more unseemly, 
and the impairment of utility more decided, than that occasioned by a 
lateral deviation. 

It may be well also to remind the surgeon of the convenience of ex- 
tending the splint beyond the end of the last phalanx, and moulding it 
to this extremity, in order that the finger may be protected against in- 
juries, and that when, from time to time, the splint is removed it may be 
reapplied with accuracy. 

In all cases the splint should be lined with cotton cloth, soft flannel, 
or sheet tint, and secured in place with narrow and neatly cut cotton 
rollers. Bandages of this width should never be torn, but carefully cut 
with scissors. 



pubes. 399 



CHAPTER XXVIII. 

FEACTURES OF THE PELVIS, AXD TEAUMATIC SEPARATIONS OF 
ITS SYMPHYSES. 

Development of the Os Innominatum. — This bone is formed from 
eight centres, three of which are called primary, and five secondary. 
The three primary centres belong respectively to the ilium, ischium, 
and pubes, and by their extension form eventually the greater portion 
of the innominatum. They have a common point of union in the ace- 
tabulum ; and the ischium unites with the pubes, also, by the junction of 
their rami. These conjunctions occur usually between the fifteenth and 
twentieth years of life. The secondary centres do not begin to ossify 
until the age of puberty, and may therefore properly be considered as 
epiphyses. One forms the ciest of the ilium; one its anterior inferior 
spinous process; one forms the symphysis pubis; one the tuberosity of 
the ischium ; while the fifth constitutes the centre of the bottom of the 
acetabulum. The epiphyses become joined to the primary bones, or the 
bodies of the innominata, at about the twenty-fifth year. 

§ 1. Pubes. 

(a) Separations at the Symphysis Pubis. 

Lente, in his reports from the New York Hospital, mentions the case 
of a young man, aet. 18, who was crushed between a couple of cars, in 
consequence of which he died two days after. The autopsy disclosed a 
separation of the symphysis pubis, unaccompanied with any other frac- 
ture. The right side was displaced backwards about half an inch, so 
that the fingers could be passed between the bones. There was also a 
wound in the top of the bladder large enough to admit the thumb. 1 
Similar accidents have been several times met with by surgeons. Hall 
reports a case in the Provincial Medical and Surgical Journal, May 1, 
1844. in which the pubes. thus separated, was actually thrust into the 
bladder: but in this example the ilium was broken also. I need scarcely 
add that this patient died; 2 but Sir Astley Cooper has furnished us with 
an example of a simple fracture or traumatic separation at the sym- 
physis, from which the patient after a long time almost completely re- 
covered. The following is Sir Astley's account of the case: 

"Case 79. Richard White, aet. 22, was admitted into Guy's Hospital 
on the 30th of July, 1832, having sustained a severe injury in conse- 
quence of a large quantity of gravel having fallen upon his back while 
in the act of stooping. It knocked him down; and on rising, which 
he did with considerable difficulty, he attempted to walk; this produced 
violent pain in the region of the bladder, extending upwards in the 
course of the ureters to the kidneys. [Jpoii inquiry, he stated that 

1 Lento. New York Journ. Med , 2d ser., vol. iv. p. 286. 

2 Hall. Amer. Journ. .Mod. Sci., vol. xxxiv. p. 248. 



400 



FRACTURES OF THE PELVIS. 



the urine he had voided since the accident was bloody and passed with 
difficulty. 

"On examination, a fissure was found at the symphysis pubis, pro- 
ducing a separation of about two fingers' breadth. On pressure being 
made upon any part of the ilium, he complained of increased pain in the 
region of the pubes, and of numbness down the left thigh. 

U A catheteT was immediately passed, and the urine which was drawn 
oft* was clear and healthy. Leeches were applied over the pubes, and 
a broad belt was firmly buckled around the pelvis sufficiently tight to 
bring the separated pubes nearly in contact, and the patient ordered to 
be kept perfectly quiet in the recumbent posture, on low diet. The 



Fig. 124. 



C ve*? 




Development of the os innorainatum. (From Gray.) 

leech-bites ulcerated, and some slight degree of fever resulted, which, 
however, readily yielded to the usual treatment. 

" He remained in the hospital for three months without any check to 
the progress of his cure; the length of time it required being accounted 
for by the difficulty of reparation in the amphiarthrodial articulation; 
and when he left there was some slight separation of the pubes remain- 
in lt: nor were the two lower extremities, or the anterior and superior 
spinous processes of the ilia, perfectly symmetrical, although he could 
walk very well." 1 

Malgaigne lias collected four cases of simple separation at the sym- 
physis pubis occasioned by external violence, and in three of the four 



1 Sir Astley Cooper, Frac. and Disloc, Amer. ed., p. 



144. 



PUBES. 



401 



eases it was occasioned by pressing out the thighs with great force ; the 
separation being directly due, therefore, to muscular action. 

Two of these patients succumbed to the accidents. The same author 
has brought together, also, seventeen cases of separations of this sym- 
physis occurring in childbirth, of which only seven survived. 



(b) True Fractures of the Pubes. 

It is much more common, however, to find the pubes broken through 
its horizontal or ascending ramus; and Clark, of the Massachusetts 
General Hospital, has described a case of simultaneous fracture of the 
pubes and ischium in three places. The man, set. 29, had been caught 
between two heavy timbers, and on the following day, May 7, 1852, he 
was brought to the hospital. 

No crepitus could be detected, but he was unable to lie upon the 
right side, and the right limb was nearly paralyzed. It was evident 
that the bladder or urethra had been ruptured, and on the third day 
Dr. Clark opened the bladder through the perineum, evacuating a large 
amount of blood and urine, and affording to the patient very sensible 
relief. On the first of June, however, he died, having survived the 
accident twenty-five days. 

The autopsy disclosed several fractures, all of which belonged to the 
right os innominatum. First, a fracture of the pubes near the symphysis ; 
second, a fracture near the junction of the pubes and ilium ; third, a 
fracture through the ramus of the ischium anterior to the tuberosity. 1 

Sir Astley mentions a case (Case 83) of fracture of the "ramus of the 
pubes," unaccompanied with injury to the bladder or urethra, which re- 
sulted in a complete recovery ; and in another case (Case 84) the patient 
recovered in eight weeks, and was 
able to walk nearly as well as before ; 
but he soon after died of disease of 
the chest. The os pubis was found, 
at the autopsy, to have been broken 
in three places ; there was also a 
fracture extending in two directions 
through the acetabulum, with an ex- 
tensive comminuted fracture of the 
ilium, accompanied with great dis- 
placement. 

Marat has even found it neces- 
sary, after ;i fracture, to remove 
nearly the whole of the body of the 
pubes by incision, in a girl of 18 
3, and who not only recovered 
completely, but. having -uh^'juently 
married, -lie gave birth to two chil- 
dren ill easy and natural labors. 2 C Iark\s case of fracture of the peWis. 

1 Clark, Boston Med. and Surg. Journ., vol. liii. p. 185. 

2 Marat, from Mal^ai^no, op. cit., p. 646. 

26 



Fig. 125 




402 FRACTURES OF THE PELVIS. 

Cappelletti relates that a man, aet. 54, jumped from a carriage, the 
horses having run away, and alighted with his feet to the ground, but 
with one limb in the greatest possible degree of abduction. A surgeon, 
who saw him immediately, found an enormous swelling at the superior 
part of the thigh, accompanied with very acute pain. When seen by 
Cappelletti, at Trieste, six months after, there still remained a slight 
swelling near the ramus of the ischium and pubes, under which a careful 
examination detected a fragment of bone two and a half inches long and 
of the "size of the finger." The patient was able to walk, but not 
without pain and limping. Cappelletti soon began to suspect that this 
fragment of bone consisted of a part of the ramus of the ischium and 
pubes detached by muscular contraction. On examining it anteriorly, 
he found this part of the pelvis defective, and the loose portion of the 
bone had all of the anatomical characters of the defective part. He 
felt distinctly the circular projection indicating the point where the as- 
cending branch of the ischium unites with the descending branch of the 
pubes. 1 

Whitaker, of Lewistown, N. Y., saw the body of the left os pubis 
broken in a female while in the seventh month of pregnancy. She had 
fallen dow r n a flight of stairs, striking astride the edge of an open, upright 
barrel. The fracture was oblique, and with but little displacement ; yet 
she complained of excruciating pain in the left pubic region on the least 
motion. The accident was followed by no positive attempt at miscar- 
riage. 2 

Prognosis. — The danger in these accidents consists not so much in the 
fracture, as in the injury done to the bladder and other pelvic viscera. 
If the bladder is opened into the peritoneal cavity, death is almost inevit- 
able ; and even when the bladder or urethra has suffered laceration lower 
down or at any point above the deep perineal fascia, extensive urinary 
infiltrations, followed by abscesses and gangrene, generally expose these 
patients to the most imminent hazards. 

Treatment. — The practice pursued at Guy's Hospital, in the case of 
separation at the symphysis pubis, commends itself both by its simplicity 
and by its success. Antiphlogistic remedies steadily pursued, rest in the 
recumbent posture, the use of the catheter when necessary, and in certain 
cases the girding the pelvis with a firm belt or band, are measures which 
seem to meet all of the important indications. 

If the fracture is accompanied with displacement, it will be proper to 
attempt to restore the fragments; but, except in the case of separation at 
the symphysis, very little aid can be expected from a band or any similar 
means in retaining them in place. It will be sufficient, generally, in 
such examples to place the patient quietly upon his back, with his thighs 
flexed upon his body, and to treat the accident in all other respects as a 
case of inflammation. 

If the urine has become extravasatcd underneath the pelvic fascia, no 
time ought to be lost in opening freely through the perineum, and in 
extending the incision, if necessary, into the urethra and bladder. 

1 Cappelletti, Banking's Abstract, No. viii. p. 83; from Giornale per servire al 
Progressi-della Eafcologie della Terrapeutica, 1847. 

2 Whitaker, Amer. Journ. Med. Sci , July, 1857, p. 283. 



ISCHIUM. 403 



§ 2. Ischium. 



When speaking of fractures of the pubes, I have already mentioned 
some examples of fractures of the ischium also ; indeed, it is seldom that 
one of the hones of the innominatum is broken without a coincident frac- 
ture of one or both of the others. The records of surgery furnish several 
other examples, produced generally by a fall upon the tuberosities ; but, 
perhaps, the most remarkable instance is that mentioned by Marat as 
having occurred in a female during labor. 

The following summary of a case of fracture of the ischium, reported 
by Sir Astley Cooper, will serve to illustrate one of the most fortunate 
terminations of these accidents when accompanied with a rupture of the 
urethra : 

A young man who was driving a cart was thrown down, and a wheel 
passed over him. On the following morning he was found to have a 
fracture of the left leg and a contusion of the inner side of the left thigh. 
There was also great swelling and ecchymosis of the scrotum, with a 
slight appearance of injury over the pubes and left hypochondrium. No 
fracture of the pelvis was at that time discovered. The patient was suffer- 
ing great pain, and was cold and exhausted. Bloody urine escaped from 
the bladder. On the eighth day an abscess had pointed on the left side 
of the perineum, which, being opened, discharged a large quantity of 
pus having the odor of urine ; extensive sloughing occurred, and the 
patient sank very low. On introducing the finger into the wound, the 
ascending ramus of the ischium could be distinctly felt, and the fracture 
traced in an oblique course, the upper fragment being slightly displaced 
forwards. When the catheter was introduced into the urethra it was 
found to enter this wound, and could be felt resting against the naked 
bone. From this time until the twenty-sixth day, the urine continued 
to escape freely through the wound. In about six weeks more the fistu- 
lous opening had entirely closed, and after several months his recovery 
was complete. 1 

Symptoms. — The signs of this accident are generally even more obscure 
than those of fractures of the pubes, but in a case of doubt the bones 
ought not only to be carefully examined from without, but the finger 
should be introduced freely into the rectum and the anterior surface ex- 
plored ; or the tuber ischii may be grasped between the thumb and finger 
and moved laterally in order to determine the existence of motion or 
crepitus. If the patient is a female, this exploration can be best made 
through the vagina. By flexing and extending the thigh, also, crepitus 
may sometimes be discovered. The examination will generally be made 
while the patient lies upon his back: but if turning is not found too 
painful, it will be well to lay him upon his face, that the tuberosities of 
the ischium may be more plainly brought into view. 

Prognosis, — A considerable proportion of the fractures of both the 
pubes and the ischium are accompanied with lesions of the bladder or of 
the urethra, either of which circumstances will lender the prognosis very 

1 Sir A. Cooper, by Btansby Cooper, Amer. ed., p. 140. 



404 FEACTUKES OF THE PELVIS. 

unfavorable: but in simple fractures recoveries may generally be expected, 
yet <>uly after a tedious confinement. 

Treatment. — It is not usual, except in cases which must almost neces- 
sarily prove fatal, to find much displacement of the fragments ; nor is it 
probable that by any manoeuvres the slight displacements which are found 
to exist can be entirely overcome. Instances may occur, however, in 
which careful pressure from without, or the introduction of a finger into 
the rectum or vagina, may aid in the restoration. 

The posture best suited to these cases will be indicated usually by the 
sensations of the patient himself. Ordinarily he will prefer to lie upon 
his back with his thighs flexed and supported by pillows ; and his hips 
slightly elevated by a firm cushion laid under the upper part of the 
sacrum. His knees ought also to be gently bound together ; but if the 
patient finds this position painful or excessively irksome, as sometimes 
he will, he may be permitted to occupy any position which he finds most 
comfortable. 

§ 3. Ilium. 

Fractures of the ilium are much more common than fractures of either 
the ischium or pubes, and they assume a great variety of forms, direc- 
tions, and degrees of complication. 

In the two following examples the anterior superior spinous process 
alone was broken off: 

John Kelly, set. 36, was admitted to the Hospital of the Sisters of 
Charity, Dec. 28, 1852, having just fallen and broken the anterior superior 
spinous process of the ilium. The fragment was displaced downwards 
about one-quarter of an inch. Motion and crepitus distinct. A slight 
ecchymosis existed over the point of fracture, and other signs of con- 
tusion about the hip were present. He was intoxicated at the time of 
the accident, and could not tell how or where he fell. 

He was laid upon his back in bed, with his thighs flexed upon his 
body; and in this position we attempted to reduce the fragment and 
retain it in place with a bandage; but finding this impossible, we left him 
with only instructions to remain quietly in bed. In about two weeks 
the fragment was firmly fixed in its new position, and he was allowed to 
get up and walk about, which he was able to do without inconvenience. 

July 13, 1853, Matthias Morrison was caught under a bank of falling 
earth, and on the following day Dr. Mixer, his attending surgeon, re- 
quested me to see the case with him. He was unable to stand upon his 
feet. There was a lacerated wound and an extensive bruise on his left 
hip: but the thigh was not shortened nor everted, and he could flex it 
slightly upon his body. Noticing a swelling and discoloration in the 
region of the anterior superior spinous process of the ilium, I pressed 
upon it and felt it recede with a distinct crepitus; the fragment, how- 
ever, ii mi icd lately resumed its place when the pressure was removed. I 
was able, also, by a careful manipulation, to trace the line of fracture, 
and to determine that it included a small portion of the anterior ex- 
tremity and wing of the pelvis. 

We directed the patient to remain quietly upon his bed, with his legs 



ILIUM. 405 

drawn up. He soon recovered, but I am unable to say what is the 
present position of the fragment. 

In the case of Mooney, aet. 60, admitted to Bellevue, September 10, 
1871, the fragment was displaced downwards one inch, and could not, 
by flexion of the limb, be replaced. It was not united at the end of 
three weeks. The ability to move his limb was unimpaired. 

More frequently, however, the fracture involves a still larger portion 
of the crest, as in the following examples : 

Joseph Joquoy, ret. 40, was caught by the bumpers between two cars, 
February 10, 1854, breaking obliquely the anterior superior portion of 
the ilium. I saw him within an hour, and found him greatly pros- 
trated: the fragment of the pelvis broken off was quite movable, and 
crepitus was easily detected. His abdomen was very tender and slightly 
bloated. 

He was laid upon his back with his legs drawn up, and hot fomenta- 
tions of hops and vinegar were directed to be applied to his belly. He 
also took one grain of morphine. The broken ala did not seem disposed 
to become displaced. With no other treatment, his recovery was rapid ; 
and the bones seemed to have united without displacement. 

James Roche, aet. 41, fell March 7, 1854, from a height of fourteen 
feet, breaking off the anterior superior portion of the right ala of the 
pelvis. On the following day I found him at the Hospital of the Sisters 
of Charity. The fragment, which was quite large, was movable, and 
occasionally a crepitus could be detected. It was displaced downwards 
and forwards about three-quarters of an inch. 

He was laid upon his back, with his thighs and limbs moderately 
flexed. At the end of two weeks he found himself able to walk without 
much difficulty, and he immediately left the hospital. At this time the 
fragment was displaced in the same manner and direction as at first, but 
1 cannot say whether it had united or not. 

I have three other similar cases upon my records ; but in the last ex- 
ample, the sixth, which has been especially recorded, the fracture was 
caused by the muscular action. William Alexander, set. 70, on the 5th 
of September, 1869, after riding in a railroad car about half an hour, 
arose to leave his seat, when he felt "something wrong" in his right 
groin, and found himself unable to walk without great pain. He was 
admitted to Bellevue Hospital on the same day, and I found a fracture 
involving about three inches of the ilium, including the anterior superior 
spinous process. It was inclined to fall outwards, but was easily re- 
placed with ;i distinct crepitus. 

I have once seen a fracture of the posterior superior spinous process, 
and I do not know of any other example. 

Miss B., aet. 19, was thrown from her horse backwards, striking with 
her back upon the ground. She was first attended by Dr. Conn, of 
Ovid. X. Y.. and Bhe did not come under my care until two weeks after 
the accident. 

I found ;i small fragment broken from the posterior superior spinous 
process of the ilium, and displaced backwards in the direction of the 
-pine about half an inch. It was movable, and by pressure it could be 
partially restored to place, but it would immediately return to its abnor- 



406 FRACTURES OF THE PELVIS. 

ma] position when the pressure was removed. The injured hip was 
painful, and occasionally it felt nuuib. She had previously suffered from 
spinal irritation. 

I laid a compress behind the fragment, and secured it in place with a 
roller, enjoining perfect rest. She recovered from her lameness in a few 
wnks, but I believe the fragment remains displaced 

Prognosis. — Extensive comminuted fractures of the ilium are gener- 
ally accompanied with so much injury of the pelvic viscera as to prove 
rapidly fatal; but the following example will show that this rule admits 
of exceptions: 

June 5, 1854, Bernard Duffie, aet. 32, was crushed under a very heavy 
stone which fell upon his back. I found the left ala of the pelvis broken 
into several fragments, between the different portions of which motion 
and crepitus were distinct. The fractures were near the superior part of 
the bone, commencing about two inches back of the anterior superior 
spinous process, and extending backwards irregularly. There was a 
narrow wound communicating with the fracture, from which I removed 
a loose fragment of bone. The right leg was also broken. 

Four months after, he was still confined to his bed, and a fistulous 
opening continued opposite the point of fracture; there existed also a 
large and irregular mass of ossific matter or callus around the fragments. 
He soon after left the hospital. 

Dr. Sargent, of the Massachusetts General Hospital, has reported a 
case in which a man received a compound fracture of the left ilium, and 
several small fragments were removed. He was discharged at the end 
of three months with a fistulous opening still remaining, but in other 
respects he was quite well. 1 Dr. Cheever, of the same hospital, reports 
a case of fracture of the ilium, with fracture of the ascending ramus of 
the pubes, resulting in complete recovery ; but the leg became shortened 
and the toes inverted. Dr. Cheever believes that the lines of fracture 
met in the acetabulum. 2 

The following case illustrates the more fatal injuries of this character: 

John O'Keaf was crushed under a heavy stone, Oct. 23, 1851, break- 
ing and comminuting the alae of the pelvis on both sides, and wounding 
also the iliac vein. He was taken to the Hospital of the Sisters of 
( 'liarity, and died in a few hours, partly from the shock to his system, and 
partly from the haemorrhage. 

Lucas 3 has also recorded two cases of lesion of this vein due to the 
same cause. 

Lente, of the New York Hospital, has reported a case of dislocation 
of the hip, which was accompanied with a fracture also of the ala of the 
pelvis upon the same side. The dislocation was reduced on the third 
dav. and the patient soon after died. The autopsy disclosed what had 
not been suspected during life, namely, that the left ilium was broken 
horizontally about through its middle, and vertically through the crest; 

1 Sargent, Boston Med. and Surg. Journ., vol. liii. p. 121. 

2 Cheever, Boston Med. and Surg. Journ., May 3, 1866. 

3 Lucas, The Lancet, 1878, vol. i. p. 147. 



ACETABULUM. 407 

and also that there was a fracture extending through the sacro-iliac syn- 
chondrosis, accompanied with considerable comminution of the articular 
surfaces. It was found that a portion of the small intestine was 
ruptured, and probably by one of the sharp fragments of the broken 
pelvis. 1 

It is seldom, I think, that the fragments become much displaced ; such, 
at least, has been my experience ; and I have noticed in Dr. Neill's 
cabinet three specimens of fracture of the crest of the ilium, all of which 
had united without any appreciable displacement. Dr. Neill also called 
my attention to the fact that in two of these specimens the ensheathing 
callus was confined to the outer surface of the bone ; an observation 
which, this gentleman assures me, he has had frequent occasion to make 
before where the fracture belonged to a flat bone. 

If any displacement exists, the upper or loose fragment is generally 
carried slightly inwards ; occasionally, however, it is found displaced 
upwards, outwards, or downwards. 

Treatment. — In a large majority of cases the fragments, if displaced, 
cannot be completely replaced. Occasionally, however, as where the 
anterior superior spinous process is broken off with only a small portion 
of the crest, the fragment may be seized with the fingers and carried 
outwards or upwards, or in whatever direction may be necessary ; but 
to retain it in this position is generally quite impossible. The bandage 
or broad belt which we have recommended in certain fractures of the 
pubes would be in these cases not only useless, but absolutely mischiev- 
ous, since its effect must be to press inwards the fragments, and thus to 
create a displacement which might not otherwise exist. 

The surgeon ought to determine by a careful examination the extent 
and direction of the fracture, and, having done what was in his power to 
replace the fragments, he should lay his patient upon his back with the 
thighs drawn up and supported. This is the position which will gener- 
ally be found most comfortable; but, as in other fractures of the pelvis, 
it may be well always to try the effect of other positions, and especially 
to determine their influence upon the fragments, and finally to adopt that 
precise posture which accomplishes the indications best. 

If the fracture is compound, and the fragments have penetrated the 
belly, the wound should be enlarged, and, as far as possible, every piece 
of bone should be removed ; but if the fragments cannot be found, the 
externa] opening should be allowed to remain so as to favor their escape 
when suppuration shall have taken place. 



§ 4. Acetabulum. 

Although, strictly speaking, fractures of the acetabulum belong 
always to one or all of those bones of the pelvis whose Lesions have 
already been described, yet the peculiar relations of this cavity to the 
femur render it necessary that they should be considered as ;i separate 
class of accidents. 

1 Lente, New fork Journ. of Med., Jan. 1851, p. 29. 



408 FRACTURES OF THE PELVIS. 

Fractures of the acetabulum divide themselves naturally into two 
varieties: 

First. Fractures of the base of the cavity, with or without displacement. 
Second. Fractures of the rim, with or without displacement. 

(a) Fractures of the Base. 

Without Displacement. — In fractures of the base of the cavity; not 
accompanied with displacement, nothing but crepitus can be present as a 
sign of the accident ; and this will scarcely be sufficient, in itself, to 
enable the surgeon to distinguish it from a fracture of the neck of the 
femur within the capsule without displacement. 

It is probable, therefore, that its existence will only be determined 
by dissection. Nor is it of much importance that the diagnosis should 
be made out ; since in either case neither splints nor any other surgical 
appliances could be of service. An injury so severe as to fracture the 
acetabulum will necessarily so much bruise the body, and concuss the 
viscera of the pelvis, as to compel the patient to remain quiet for a 
number of days, and this is all that would be thought necessary if the 
nature of the accident was exactly determined. 

Dr. Neill's cabinet contains a specimen of this kind, in which the 
fracture, commencing near the centre, extends in three directions across 
the cotyloid margins, in which perfect bony union has occurred without 
displacement. 

M. Bouvier related to the Academy the case of a man, set. 71, who, 
in consequence of a fall from his bed, remained for three weeks unable 
to walk, and never was able afterwards to walk without crutches. No 
fracture could be discovered during life, but after his death, which oc- 
curred some months subsequent to the accident, a fracture was found 
extending from the ilio-pectineal eminence to the spine of the ischium, 
and traversing the centre of the acetabulum. The fragments were not 
displaced, but remained slightly movable. 1 

With Displacement. — Fractures of the base of the acetabulum, w T ith 
displacement of the femur into the pelvic cavity, constitute a much more 
formidable, and unfortunately a more common form of accident. 

Like the preceding variety of acetabular fractures, they are produced 
generally by falls upon the trochanter major, but the force of the con- 
cussion has been greater. 

Even here, it is not often that the diagnosis has been clearly made out 
during life ; and indeed, generally, the true character of the accident 
has not even been suspected, the surgeons believing that they had to do 
with a fracture of the neck of the femur, or with a dislocation. In two 
examples (Cases 71 and 72) mentioned by Sir Astley Cooper as having 
been presented at St. Thomas's Hospital, the thigh was thought to be 
dislocated backwards. 

The following case was reported by Mr. Earle, to the London Medico- 
Chirurgical Society, and will be found in the nineteenth volume of its 

1 Bouvier, Amer. Journ. Med. Sci., vol. xxiii. p. 486; from Bullet, de l'Acad. 
Roy. de Med., August 15, 1838. 



BASE OF THE ACETABULUM. 409 

Transactions. It is also referred to by Sir Astley, in his treatise on 
Fractures and Dislocations : 

In the month of October, 1829, a man, set. 40, was admitted into St. 
Bartholomew's Hospital, with a severe injury, caused by having fallen 
from a height of thirty-one feet, and striking upon the left side. The 
left leg was powerless and shortened. The foot was everted. Any at- 
tempt to rotate the limb caused great pain, and was accompanied with a 
sensible crepitus. The left trochanter was very much depressed, and 
when it was pressed upon, the patient complained of deep-seated pain in 
the hip-joint. 

He recovered in eight weeks, and was able to walk nearly as well as 
before : but he soon after died of disease in the chest. 

On dissection, a fracture was found extending in two directions 
through the acetabulum ; there was an extensive comminuted fracture of 
the ilium, with great displacement, and the os pubis was broken in three 
places. 

The repair was very complete, and Mr. Earle remarked how nature 
had guarded against any considerable deposit of new bone within the 
articulation, which might have interfered with the functions of the joint, 
while there was an abundant deposit of callus around the other parts of 
the fractured bone. 

Mr. Travers has reported two similar cases, and in the paper accom- 
panying the report he maintains that very acute pain caused by pressing 
upon the projecting spine of the os pubis, and the inability of the patient 
to maintain the erect posture, may be regarded as signs diagnostic of the 
accident. 1 It is doubtful, however, whether these phenomena, so com- 
mon to many other accidents, could be relied upon as evidence of this 
peculiar lesion. 

In the following example reported by Lendrick, of Dublin, the patient 
was -apposed to have a fracture of the neck of the femur: 

An old man, well known as the " Wandering Piper," was admitted 
into the Mercer Hospital in January, 1839, suffering from phthisis pul- 
monale and acute inflammation of the hip-joint. Some years before, he 
bad received a severe injury by the upsetting of a coach, and was under 
treatment several months for what was supposed to be a fracture of the 
neck of the femur. Since that time he had been lame, but still able to 
take a great deal of exercise on foot both in Great Britain and in Amer- 
ica. The acute disease of the joint commenced about two months before 
his admission, and he was at first under the care of Sir Philip Crampton, 
who remarked that the thigh was only shortened about half an inch, and 
expressed his surprise at this fact. 

This man died on the 17th of February, and the dissection showed 
that there had been no fracture of the femur, but its head and neck 
were affected with "morbus coxae senilis." The head was also thrusl 
through a rem in the acetabulum into the cavity of the pelvis ; but the 
head had again been covered by a bony case, complete, except in a 
small portion about the size of a shilling piece, and at this point the 
covering was ligamentous. 

1 Travera, Holmes's System of Surgery, vol. ii. p. 178. 



410 FRACTURES OF THE PELVIS. 

The os pubis had also been broken at the same time, and it had 
united so niiK'h overlapped that the space between the inferior anterior 
spinous process and the symphysis pubis was shortened nearly an inch. 
A portion of intestine was found protruding through an opening in the 
pelvis and adherent to the bone, in which situation it seemed to have 
been caught by the broken fragments and retained. 1 

Morel-Lavallee, in his thesis upon complicated luxations, mentions a 
case which had come under his observation, and which had been treated 
as a fracture of the neck of the femur. The patient survived the acci- 
dent many years ; during a part of which time he suffered such pain in 
the hip-joint as to induce a belief that it Avas itself diseased. At his 
death he was found to have had a multiple fracture of the bones of the 
pelvis, and the head of the femur had penetrated more than an inch into 
the cavity of the pelvis, pressing upon the obturator nerve to such a 
degree as to have, no doubt, caused the severe pain from which he had 
suffered, and which had been ascribed to coxalgia. 2 

Symptoms. — In the two cases mentioned by Sir Astley Cooper as 
having been received into St. Thomas's Hospital, the toes were turned 
in. In the example mentioned by the same author as having been pre- 
sented at St. Bartholomew's Hospital, the toes were everted ; the two 
persons seen by Lendrick and Morel-Lavallee were supposed before death 
to have had a fracture of the neck ; it is probable, therefore, that in both 
of these cases the toes were also everted ; while Moore has dissected a 
subject whose pelvis was broken into many fragments — the left os in- 
nominatum was divided into three portions, corresponding to the three 
bones of which it was composed in infancy ; the head of the femur had 
completely penetrated the basin ; the limb was shortened two inches, 
and in a position of slight flexion and adduction, but neither rotated 
outwards nor inwards. 3 

There seems, therefore, to be no certain rule in relation to the posi- 
tion of the limb ; but it is found to take the one position or the other, 
probably according to the direction of the force which has inflicted the 
injury, and perhaps in obedience to circumstances not always easily 
explained. 

The shortening has been observed to vary from half an inch to two 
inches or more ; the trochanter is also usually driven in toward the 
pelvis. Pressure upon the trochanter occasions a deep-seated pain. If 
the limb is drawn down to the same length with the other, it immedi- 
ately resumes its position when the extension is discontinued. Crepitus 
is more uniformly present than in fractures of the neck of the femur, 
and it is especially felt while the limb is being extended or while it is 
again shortening, and not so much in flexion or rotation. 

If, in addition to all of these phenomena, we learn that the accident 
has occurred from a severe blow, or a fall from a great height upon the 
trochanter; and that the viscera of the pelvis, and especially the bladder, 
seem to have suffered considerable injury; or if we detect at the same 

1 Lendrick, Amer. Journ. Med. Sci., vol. xxiv. p. 481 ; August, 1839; from London 
Med. Gazette, March, 1839. 

2 Morel- Lavellee, from Malgaigne, op. cit., vol. ii p. 881. 

3 Moore, Med.-Chir. Trans., vol. xxxiv. p. 107, 1851. 



RIM OF THE ACETABULUM. 411 

time a fracture of some other portion of the pelvis — we may reasonably 
conclude that the head of the femur has penetrated the acetabulum. 
Yet it must be confessed that no one of these symptoms is positively 
distinctive of this accident, and that they are seldom found sufficiently 
grouped to render the diagnosis certain. Possibly the displacement may 
be detected by the finger introduced into the rectum or vagina. 

The old "piper" mentioned by Lendrick, and the man dissected by 
Morel-Lavallee, lived many years, and managed to walk about, but not 
without considerable pain; the other three, to whom I have alluded, died 
soon after the injuries were received. 

Treatment. — Some have thought of treating these cases by extension 
and counter-extension ; the latter being accomplished through the aid of 
a perineal band ; but it is not probable that after an injury of this char- 
acter, any patient will be able to endure the requisite pressure about the 
perineum or groins. It will be better to lay the patient upon Daniel's 
invalid bed, or some bed similarly constructed, so that it may be con- 
verted into a doubled-inclined plane ; allowing the knees to be suspended 
over the angle thus formed, in order that the weight of the body may 
have some effect to draw away the pelvis from the femur. Or we may 
adopt extension without the perineal band, as will be described hereafter 
when treating of fractures of the femur ; or we may resort to Hodgen's 
suspension apparatus. 

(b) Fractures of the Rim. 

Fractures of the rim of the acetabulum have frequently been dis- 
covered in dissections ; and the records of surgery abound with cases of 
unreduced dislocations of the femur, in which the failure to reduce or to 
retain the bone in place has been ascribed, not always with sufficient 
. perhaps, to this fracture. 

Dr. McTyer, of the Glasgow Royal Infirmary, published, in the Grlas- 
goiv Medical Journal for February, 1830, four cases of this fracture. 

The first was that of a man, aet. 27, on whose back a number of bricks 
had fallen while he had his right knee placed on the bank of a trench. 
Hi- right log Avas found shortened about one inch and a half, bent, and 
the toes turned a little outwards. The limb could be moved without 
much difficulty, but every motion gave him pain; motion was also at- 
tended with crepitus. On making extension, the limb was easily brought 
to the same length with the other, but it became shortened again imme- 
diately when the extension was discontinued. 

The symptoms, differing but little, if at all, from those which are 
usually present in a case of fracture of the neck of the femur, led to 
the supposition that this was actually the nature of the accident. Sub- 
sequently, the toes became slightly turned in, but this circumstance 
was not regarded as Hiffieiently distinctive to warrant a change in the 
diagnosis. 

Having succumbed to the injuries after a few days', the autopsy re- 
vealed a fracture extending through the bottom of the right acetabulum, 
and about one inch and a half of the rim at its upper and posterior 
margin completely detached, except as it was held in place by a portion 
of the capsular ligament. The head of the bone could be easily pushed 
upwards and backwards upon the dorsum, the fragment of the acetabular 



412 FRACTURES OF THE PELVIS. 

margin being moved aside, and swinging upon its fibrous attachment as 
upon a hinge, but resuming its place again perfectly when the head of 
the femur was restored to the socket. The femur was not broken. 

In the second case the limb was found shortened, the knee slightly- 
bent, and turned a little forwards and inwards, and the toes pointing to 
the tarsus of the other foot. It was thought to be a fracture also of the 
neck of the femur, but the autopsy disclosed only a fracture of the upper 
margin of the rim of the acetabulum. 

In the third case, seen only after death, the limb was not shortened 
much, but the toes were stretched downwards, and turned slightly in- 
wards. It was supposed at first to be a simple dislocation, but on dis- 
section the posterior and inferior margin of the acetabulum was found to 
be broken and displaced toward the coccyx, while the head of the femur 
rested upon the pyriformis muscle, over the ischiatic notch. 

The fourth example was found in the dissecting-room, and the history 
of the case is not known. A fragment of the superior and posterior 
margin of the acetabulum had been broken off, and had reunited slightly 
displaced. 1 

Causes and Symptoms. — Several other similar examples have been 
established by dissection ; 2 and Dr. Nicholas Senn, of Milwaukee, Wis- 
consin, has collected a number of examples more or less satisfactorily 
demonstrated without the aid of an autopsy. 3 . We are able, therefore, to 
determine pretty accurately what are the usual causes, phenomena, and 
terminations of this accident, though we are far from having arrived at 
a satisfactory means of diagnosis. Its causes are generally the same 
as those which produce dislocations of the hip, but in most instances 
the violence has been greater than in the case of dislocations. In a case 
reported by Miner 4 it was the result of a gunshot ; the fragment having 
escaped through a fistulous opening. 

The symptoms are, first, such as indicate a dislocation, to which must 
be added crepitus and a difficulty, if not impossibility, of retaining the 
head of the femur in its place when it is reduced. The crepitus is 
sometimes discovered the moment we begin to move the limb, and this 
will aid us to distinguish it from a fracture of the neck of the femur 
accompanied with much displacement, since, in the latter case, crepitus 
is not felt usually until the extension is complete, and the fragments are 
again brought into apposition. 

Prognosis. — Some of these accidents, either from a failure to recog- 
nize them, or from the impossibility of maintaining the head of the 
femur in place when once it has been reduced, have resulted in a perma- 
nent dislocation of the hip and a serious maiming. In nine out of thir- 
teen cases w/nch Senn has found reported, the reduction was maintained, 
and in four it was not. The following case was recognized and reduced, 
but it was found impossible to maintain the reduction. 

1 McTver, Amerv Journ. Med. Sci., vol. viii. p. 517, Aug. 1831. 

- Maisonncuve, Chirurg Clin., 1863, p. 168. Sir Astley Cooper on Disloc. and 
Frac., 1823, second London edition, p. 15. M. Beraud, Bulletin de la Soc. de Chir., 
1862, torn. iii. p. 185. Ibid., p. 226. Bigelow on Hip-Joint, 1869, p. 139 et seq. 
Eve, British Med. Journ., Jan. 24, 1880 (2 cases). Agnew, Treat, on Surgery, vol. 
i. p. 929. 

3 Senn, Trans. Wisconsin State Med. Soc, 1880. 

4 Miner, Buffalo Med. and Surg. Journ., vol. v. p. 383. 



RIM OF THE ACETABULUM. 413 

February 3, 1847, a strong German laborer was crushed under a mass 
of iron weighing several tons. Drs. Sprague and Loomis, of Buffalo, 
were called, and found the left thigh dislocated upwards and backwards, 
and by the aid of six men they succeeded in reducing it, the reduction 
being attended, as the gentlemen informed me, with a slight sensation of 
crepitus. The legs were then laid beside each other, and the knees tied 
together, the patient lying on his back ; and now the two limbs appeared 
to be of the same length. On the second and third days the injured 
limb was examined by the same gentlemen, and there was no displace- 
ment. On the fourth day I was invited to meet these gentlemen, the 
patient having had muscular spasms during the previous night, and the 
thigh being redislocated. I found the limb shortened one inch and a half, 
adducted, and the toes turned in. We immediately applied the pulleys, 
and soon drew the trochanter down to a point apparently opposite the 
acetabulum, and a careful measurement showed that the two limbs were 
of the same length. The pulleys being removed, the leg did not draw 
up again, nor did the foot turn in, yet we had felt no sensation to indi- 
cate that the bone had slipped into its socket, nor had we felt crepitus. 
The legs and thighs were now laid over a double-inclined plane, and well 
secured. He remained in this condition three days more, during which 
time Dr. Sprague saw him each day, and found nothing disarranged. 
On the night of the seventh day the spasms returned, and in the morn- 
ing the thigh was displaced. 

The next day we again applied the pulleys, but soon found that the 
bone would not remain in place one minute after the pulleys were re- 
moved. 

At this time, while moderate extension was being made at the foot by 
rotating the foot inwards, we could distinctly feel a slight crepitus. A 
straight splint was applied, and as much extension made as he could 
conveniently bear, and in this condition the limb was kept several weeks. 
Seven years after, I found the thigh still displaced upon the dorsum ilii. 
He limped badly, but he could walk fast, and perform as much labor as 
before the accident. 

In one case mentioned by Mr. Keate, the bone had become dislocated 
downwards, and could be felt lying against the tuber ischii, and the 
presence of a "distinct grating as of ruptured cartilage" led him to 
conclude that the cartilaginous labrum of the socket was broken off; but 
a- the fracture was in the lower margin of the socket, no difficulty was 
experienced in retaining the bone in position. 1 

Dr. Homer ( ). Hitchcock, of Kalamazoo, Mich., reported to the 
Michigan Medical Society, June 12, 1879, a case of supposed fracture 
of the rim of the acetabulum, accompanied with a backward dislocation, 
which was successfully reduced and retained in place seven or eight 
weeks after the- accident, by Dr. Noyes, of Detroit. The surgeons who 
bad charge of the patient ;it first were prosecuted, and a judgment was 
obtained for damages, but this was finally reversed and the surgeons 
fully exonerated. As to what was the precise nature of the case the 
a _ <>ris who testified were not agreed, and perhaps nothing but an 
autopsy could determine. 

1 Keate, Amer. Journ. of Med. Bci., vol. xvi. p. 225. 



414 



FRACTURES OF THE PELVIS. 



Dr. 0. II. Walker, of Detroit, Michigan, presented to the Detroit 
Academy of Medicine, May 27, 1879, a specimen of this fracture, the 
history of which was as follows: A man, aet. 78, falling upon his hands 
and knees, was struck on the lower portion of his back by a passing 
street-car. He was taken to a hospital, and was found to have a disloca- 
tion upon the dorsum ilii. Reduction was readily accomplished, and 
crepitus was recognized, but its seat not fully determined. The patient 
died in a few hours from shock. In the autopsy the head of the femur 

was found in the socket, but it w T as 
easily displaced. The ligamentum 
teres and a greater part of the pos- 
terior half of the capsular ligament 
were torn away, leaving a part of the 
anterior portion, together with the 
ilio-femoral ligament, untorn. Some 
of the gluteal muscles were torn 
from their femoral attachments. The 
greater portion of the posterior lip 
of the acetabulum was torn away, 
making an opening through which 
the head of the femur had escaped, 
passing between the fasciculi of the 
ilio-femoral ligament, and resting 
finally near the crest of the ilium. 
Less than one-third of the normal 
depth of the acetabulum remained 
to support the head of the femur 
when it was in place. 1 Dr. Walker 
incidentally mentions that Brodie reported a case which he supposed to 
be of this nature, in the London Lancet, in 1833. 

Treatment. — If the diagnosis is satisfactorily made out, and upon 
complete reduction the femur will not remain in place, the treatment 
ought to be nearly the same as for fracture of the thigh, except that no 
lateral splints or bandages to the thigh will be necessary. If the straight 
position is chosen, the limb ought to be rotated in a direction opposite to 
that in which the acetabular margin is supposed to be broken, and kept 
drawn out to its proper length, as far as this shall be found to be practi- 
cable, by extending and counter-extending apparatus. A band around 
the pelvis, so adjusted as to press the head of the bone into its socket, 
may also be of service in preventing the tendency to displacement; and 
in case the bone manifests little or none of this tendency, the hip band- 
age will probably alone be sufficient, yet even here no harm could come 
of applying the extending apparatus, secured moderately tight, simply as 
a measure of precaution. Dr. Bigelow recommends angular extension, 
eTectcd by means of an angular splint, such, for example, as Nathan R. 
Smith's, or Hodgen's, suspended from the ceiling, or from some other 
point above the patient; "or," he adds, "if any manoeuvre has reduced 
the bone, the limb should be retained, if possible, in the attitude which 
completed the manoeuvre." 




i of fracture of the acetabulum. 



1 Walker, Detroit Lancet, July, 1879. 



SACRUM. 415 



§ 5. Sacrum. 



Simple fractures of the sacrum, known to be exceedingly rare, 1 are 
occasioned either by such injuries as break at the same time the other 
bones of the pelvis, or by blows or falls received directly upon the sacrum, 
It may be broken at any point, and in any direction, when the fracture 
is produced by the first of this class of causes ; but if the fracture is the 
result of a fall upon the sacrum, it will generally be transverse, and be- 
low the sacro-iliac symphysis. The displacement in this latter class of 
cases is almost invariably the same, the coccygeal extremity being sim- 
ply carried forwards, yet this is seldom sufficient to interfere in any de- 
gree with the functions of the rectum and anus ; but in one case seen by 
Bermond it nearly closed the rectum. Sometimes, also, there is a slight 
lateral deviation. There is also in the Dupuytren museum, at Paris, a 
specimen in which the whole of the lower fragment is displaced a little 
forwards. 

Symptoms. — The signs of this fracture are pain at the seat of injury, 
aggravated greatly in the attempts to flex or elevate the body, and espe- 
cially in the efforts at defecation ; swelling and discoloration of the soft 
parts covering the sacrum ; displacement of the coccyx forwards ; an 
angular projection at the point of fracture, with a corresponding retiring 
angle upon the opposite side ; mobility. 

Prognosis. — Experience has shown that where the fracture of the 
sacrum is accompanied with other fractures of the pelvis, the patients 
seldom recover ; and only because so extensive an injury implies usually 
great force in the cause which produced the fractures, and, of necessity, 
greater lesions among the pelvic viscera. Simple fractures, from falls 
upon the sacrum, occurring below the sacro-iliac symphysis, are gener- 
ally followed by speedy recoveries, although the inward displacement is 
not often completely overcome. 

Treatment. — By introducing a finger into the rectum, the low T er frag- 
ment can be easily pressed back to its natural position, but the difficulty 
consists in finding any means of retaining it there until bony union is 
effected. Judes succeeded to his satisfaction with a wooden cylinder, 
which he compelled the patient to wear forty-five clays; removing it, 
however, every third day, in order to cleanse the rectum with an enema. 
Bermond introduced first a linen bag, which he immediately proceeded 
to fill with lint; but during the night it became necessary to remove it, 
in order to relieve the bowels of wind and stercoraceous matter. He 
now substituted a silver canula covered with a shirt, which latter he 
filled with lint in the same manner as before. This was retained without 
much inconvenience nineteen days; having only been removed once 
during this time. The union now seemed to be firm, and the apparatus 
was removed. Plugging the rectum in this manner may be necessary 
whenever the inward inclination of the lower fragment is found to be 
considerable, but not otherwise ; ordinarily it will be sufficient to lay the 
patient upon his back, with a firm cushion above the point of fracture, 

1 Malgaigne has referred to eight cases; and I have not been able to find a record 
of any others. 



416 FRACTUKES OF THE PELVIS. 

so as to prevent the bed from pressing in the lower fragment; and having 
emptied his rectum thoroughly by an enema of warm water, he should 
be placed under the influence of an opiate sufficiently to restrain the 
action of the bowels for several days, or for as long a time as may be con- 
sistent with health or comfort. To the same end, also, the diet ought to 
be light and dry ; nothing should be allowed which might prove laxative. 
By constipating the bowels, two ends may be gained. We shall prevent 
that frequent action of the sphincters, which might tend to disturb the 
union ; and the hardened faeces, by their accumulation in the rectum, 
may serve to press back the lower fragment of the sacrum, in a manner 
much more natural and quite as effective as any apparatus which can be 
contrived. 

Separations at the Sacro-iliac Symphyses. 

I have already mentioned a case of separation of the bones at the sacro- 
iliac symphysis, reported by Lente, but which was accompanied also with 
a fracture of the ilium and a dislocation of the hip. Several other similar 
examples have been reported, in some of which both of the sacro-iliac 
symphyses have been separated, or displaced. Such accidents are the 
results only of great violence, and the subjects of them seldom recover. 

Dr. J. T. Banks, of Griffin, Ga„ has reported one example of complete 
recovery in an adult male, in which the right sacro-iliac symphysis was 
separated "by a blow received upon the tuberosity of the ischium, driv- 
ing the ilium up an inch or more, causing complete paralysis and anaes- 
thesia of the right leg for two or three weeks ; " motion of the hip caused 
also severe pain. No attempt was made to reduce the bones, but union 
occurred, and he gradually regained the use of his limb. 1 In a few in- 
stances this articulation has been known to give way during labor, while 
the symphysis pubis has suffered little or no diastasis ; and in these cases 
recovery has generally taken place. 

In nearly all the traumatic examples reported, the diastasis has been 
accompanied with a fracture extending parallel with the margins of the 
synchondrosis ; and it is for this reason that I have preferred to con- 
sider these accidents as fractures, rather than as dislocations. 

§ 6. Coccyx. 

The bones which compose the coccyx, four in number, develop slowly, 
the third not presenting an ossific nucleus until from the tenth to the 
fifteenth years of life, and the fourth not until between the fifteenth and 
twentieth year. Subsequently the first and second become united into 
one, and later the third and fourth are united into one; finally the 
second and third unite, and the coccyx is complete as a single bone. At 
a late period of life, later in the female than in the male, the coccyx is 
united by bone to the sacrum. These facts render it apparent that a 
true fracture can scarcely occur until late in life ; and it seems probable, 
also, that a diastasis or dislocation will be very unlikely to occur. For 
myself, I have never met with the accident in any of its forms. Mal- 
gaigne says he has seen one example of fracture in an autopsy, in which 

1 Banks, Atlanta Med. and Surg. Journ., May, 1866. 



coccyx. 417 

case there was also a fracture of the sacrum ; and he adds that Cloquet 
had seen another in an old man. caused by a kick. 

Treatment. — In case a fracture were to occur, the treatment would be 
the same as that already described for a fracture of the lower portion of 
the sacrum. 

Dr. Geo. A. Mursick, of Xyack, Xew York, reports 1 two cases of 
" coccygodynia," in which he practised excision of the last two bones 
of the coccyx successfully. One of them was a case of fracture, with 
forward displacement, in a woman twenty-nine years old, and was caused 
by a fall upon the nates. Fourteen months after the accident she came 
under Dr. Mursick 's observation. She was suffering great pain in the 
pelvic region, and especially in the region of the rectum, which was 
aggravated by walking, defecation, and by rising from the sitting 
position. 

June 2, 1873, Dr. Mursick removed the last two bones of the coccyx, 
the patient being under the influence of ether, by making an incision 
posteriorly of two inches in length, exposing the bone thoroughly, and 
then having seized the bone with a pair of forceps, it was drawn out and 
carefully dissected from its attachments. Severe pains in the pelvic 
region followed the operation, with retention of urine, and the wound 
healed slowly. 

Aa a result of his two operations he concludes that the operation is 
simple and easy of performance, but that the constitutional disturbance 
which ensues is out of all proportion to its magnitude. The subsequent 
pain is very severe, and lasts for several days ; and the wound heals 
slowly. 

I am also indebted to Dr. Mursick for the statement, that extirpation 
of the coccyx has been practised occasionally since the first differentia- 
tion of coccygodynia by Xott and Simpson, with successful results, but 
especially in those cases which were of traumatic origin. In other 
cases, unaccompanied with fracture or dislocation, subcutaneous incision 
of the attachments of the coccyx has proved sufficient, while in many 
cases, of purely neurotic origin, the cure has, after a time, been effected 
without resort to surgical interference. My own experience confirms 
this latter statement. Xor can I fully appreciate the necessity or ad- 
vantage of resection in any case of simple fracture or diastasis of this 
bone. In the case related by Mursick there is no evidence furnished 
that union had ever taken place between the second and third portions, 
and the age permits a presumption that it had not, and that it was not 
therefore in reality a fracture ; but even if it had been, what possible 
harm could come of its being rendered movable by the fracture, since if 
it were movable it could not interfere with defecation ? The coccyx is 
not without its function, and cannot without injury be lost, inasmuch as 
it serves for the attachment of muscles and ligaments, most of which are 
of importance in connection with defecation, and occlusion of the rectum.. 

1 Mureick, American Journal of the Medical Sciences, Jan. 1876, p. 122. 



418 



FRACTURES OF THE FEMUR. 



CHAPTER XXIX. 



FRACTURES OF THE FEMUR. 



Fig. 127. 



Development of Femur. — The femur is formed from five centres of 
ossification : namely, one for the shaft, commencing at about the fifth 
week of foetal life ; one for the lower end, including 
the condyles, commencing at the ninth month of foetal 
life ; one for the head, commencing at the end of the 
first year after birth ; one for the great trochanter, 
commencing during the fourth year ; and one for the 
lesser trochanter, commencing between the thirteenth 
and fourteenth years. None of these epiphyses are 
joined to the shaft until after puberty, but consolida- 
1 m/ tion is generally completed at the twentieth year. 

1 " I The order in which union occurs is the reverse of the 

1 1 ', \ order in which ossification commences, the lower epi- 

tji pbysis being the first to exhibit traces of ossification, 

i 'I! and the last to unite. 

* I Division of Fractures. — Of 236 fractures of the 

femur, not including gunshot, which have been re- 
corded by me, 114 belong to the upper third, 86 to 
the middle third, and 36 to the lower third ; or, if we 
confine our analysis to the shaft alone, 30 belong to 
the upper third, 80 to the middle, and 36 to the lower. 
(I have personally examined many more cases of 
fracture of the femur than are enumerated above, but 
these include all which have been subjected to this 
species of analysis.) 

Dr. Frederick E. Hyde, in his analysis of 322 
cases, in Bellevue Hospital, states that 95 occurred in 
the upper third (including fractures of the neck); 169 
in the middle third, and 38 in the lower third (includ- 
ing the condyles). In the 20 remaining cases the 
point of fracture is not stated. 
To give a summary of these valuable tables more in detail, 61 be- 
longed to the neck, of which 14 are stated in the records to be intra- 
capsular, 17 extracapsular, and thirty undetermined. Thirty-four were 
in the upper third of the shaft ; 169 in the middle third, and 31 in the 
lower ; the exact point of fracture of the shaft being undetermined in 20; 
7 fractures belonged to the condyles. 1 

The femur constitutes, therefore, a striking exception to the rule 
Avhich my observations have established, that in the case of the long 



-4 



Development of fe- 
mur. (From Gray. ) 



1 Hyde, Analysis of 322 cases of Fracture of the Femur, at Bellevue Hospital, from 
1865 to 1873, inclusive. Medical Kecord, 1875. 



XECK OF THE FEMUR. 419 

bones the lower third is most often the seat of fracture. The shaft of 
the femur is most often broken in the middle third, and generally near 
the upper end of this third : that is to say, above its middle. 

§ 1. Neck of the Femur. 

Eighty-four of the whole number recorded and analyzed by myself 
were fractures of the neck, either intra- or extracapsular. The youngest 
of these patients, excepting one case of supposed epiphyseal separation, 
was twenty-nine years, the oldest eighty-four ; forty-five were males and 
thirty-nine females. Nearly all were simple. Forty-two were believed 
to be without the capsule, and thirty were believed to be within ; the 
remainder were undetermined. 

"We have already given the number of fractures of the neck, both 
intra- and extracapsular, reported in Dr. Hyde's tables. Having refer- 
ence to age. 19 years was the youngest, and 85 the oldest ; 20 years 
and under presented two cases ; from 20 years to 30, five cases ; from 
30 to 40. nine ; from 40 to 50, eight ; from 50 to 60, fourteen ; from 60 
to 7". fifteen: from TO to 80, seven; from 80 to 90, one. Of the whole 
number, thirty-nine were males, and twenty -two females ; none of the 
fractures were compound : fourteen are recorded as of the right leg ; 
seventeen of the left : and thirty are undetermined. Fourteen were 
diagnosticated as intracapsular, and seventeen as extracapsular, thirty 
being undetermined. 

Surgeons have differed in their opinions as to the relative frequency 
of fractures of the neck of the femur within or without the capsule. 
This has arisen, no doubt, in part from the difficulty and probable inac- 
curacy of many of the diagnoses. Malgaigne, who has adopted a mode 
of deciding this question which, it must be conceded, is much less liable 
to error than simple clinical observation, namely, an examination of 
cabinet specimens, finds in four large collections sixty-one intracapsular 
fractures, and only forty-two extracapsular. So that, according to his 
rations, they stand in the proportion of about three to two ; the 
intracapsular being the most common. On the contrary, Nelaton believes 
that extracapsular fractures are much the most common, and Bonnet, of 
s, affirms that they constitute the immense majority. Bonnet made 
four dissections, and in each case he found the fracture extracapsular. 
This testimony, bo far as it goes, is positive, but the number is not suf- 
ficient to establish anything more than a probability in favor of the 
ter frequency of extracapsular fractures. 

Clinical observation- are in this case too uncertain to be made avail- 
able in 80 nice a question. Cabinet specimens may have been collected 
for a special purpose, and this is well known to have been the fact with 
the celebrated Dupuytren collection, the specimens in which constitute 
nearly one-third of the whole number referred to by Malgaigne. I allude 
to the effort which was made while the controversy was pending between 
Dupuytren and Sir Astley Cooper as to the probability of bony union in 
intracapsular fracture-, to accumulate cabinet specimens of this fracture; 
and which effort extended itself, no doubt, both to London and Dublin, 
from which two latter sources Malgaigne has gathered the remainder of 



420 FRACTURES OF THE FEMUR. 

his figures. In Dr. Mutter's collection, at Philadelphia, I think there 
are only three examples of intracapsular fracture, to seven extracapsular. 

Dr. Reuben D. Mussey, of Cincinnati, has in his cabinet twelve ex- 
amples of fractures of the neck of the femur without the capsule, and 
only ten within. 

We ought, therefore, to regard the question of relative frequency as 
still undetermined. Nevertheless, it is my opinion that the extracapsular 
fracture is very much the most frequent. 

(a) Neck of the Femur, within the Capsule. (Intracapsular.) 

Causes. — In no other fractures do the predisposing causes play so im- 
portant a part as in fractures of the neck of the femur, and this whether 
within or without the capsule ; indeed, experience has shown that without 
the concurrence of those pathological changes which usually accompany 
old age, these fractures can scarcely occur. 

Dr. Merkel considers the fragility of the neck, within the capsule, in 
old persons, due to the absorption of that process of the cortical sub- 
stance which arises from about the level of the trochanter minor, and 
ends close under the head of the bone, at the anterior part of the neck ; 
thus occupying the situation where the greatest pressure is made in the 
erect position. This process he calls the "calcar femorale." In newly 
born children it is absent ; it appears when they begin to walk, attains 
its greatest development in middle age, and completely disappears in old 
persons. 1 Dr. Merkel says that no account has hitherto been given of 
this process ; but this statement is scarcely correct, inasmuch as it has 
been both described and represented by various surgical and anatomical 
writers for a long time (see Fig. 131 of this volume). The fact of its 
absorption in advanced life is, however, an original observation. 

Sir Astley Cooper thought that the majority of fractures of the neck 
after the fiftieth year were intracapsular ; but Robert Smith has given 
us the ages of sixty persons having fractures of the neck of the femur, 
and the average age of thirty-two in whom the fractures were within the 
capsule, is sixty-two years, while the average age of twenty-eight in 
whom the fractures were extracapsular, is sixty-eight years. Malgaigne 
has referred to this testimony in proof of the inaccuracy of the opinion 
held by Sir Astley Cooper; but I trust it will not be regarded imperti- 
nent or hypercritical for us to inquire how Mr. Smith became possessed 
of the ages of all these persons from whom these specimens were ob- 
tained ; for more than half of the whole number, that is, just thirty-two, 
have their ages set down in round decimals, such as 50, 60, 70, etc., and 
it would be easy to show, by the inevitable law of chances, that this could 
not possibly be a true statement. If Mr. Smith does not pretend to 
have given the ages with accuracy, but only to have arrived as near to 
the truth as his sources of information ayouIc! permit, then I protest that 
these tables do not constitute proper evidence in relation to this point; 
and until better evidence is furnished I shall continue to think, with Sir 
Astley Cooper, that fractures within the capsule belong generally to an 

1 Merkel, Am. Journ. Med. Sci., Jan. 1874. 



NECK, WITHIN THE CAPSULE. 421 

older class of subjects than fractures without the capsule. This opinion, 
confirmed by my own experience, does not, however, as Malgaigne seems 
to think, imply that fractures within the capsule may not occasionally 
occur in persons much younger than the average limit, namely, under 
fifty years. 

Dr. Hyde's tables present two cases under 50 years, and twelve at or 
over 50. Of the two under 50 years, one was 48 years of age, and the 
other 39. Of course, the reader will make what allowance he shall think 
proper as to the accuracy of these diagnoses, inasmuch as such diagnoses 
are notoriously difficult, and often inaccurate. 

It is also believed that intracapsular fractures are more frequent in 
women than in men. In Dr. Hyde's tables there are ten females and 
four males. 

The position of the neck of the femur, and the great thickness of the 
muscular coverings, render its fracture from a direct blow a very rare 
circumstance; indeed, it can only happen as the result of gunshot acci- 
dents, or other similar penetrating injuries. 

It is broken, therefore, usually by indirect blows, such as a fall upon 
the bottom of the foot, upon the knee, or upon the trochanter major ; or 
by muscular action alone, as has sometimes happened with very old peo- 
ple, who, in walking across the floor, have tripped upon the carpet, 
breaking the bone in the effort to sustain themselves. We must not 
always infer, however, because the patient has tripped, that the bone was 
broken by muscular action ; since it is quite as likely that the fall, con- 
sequent upon the tripping, has occasioned the fracture ; and we ought in 
such cases to make a careful examination of the hip over the trochanter 
to ascertain whether it has been bruised, and to interrogate the patient as 
to the manner of the fall. 

Riedinger 1 thought he had met with an impacted fracture of the neck 
caused by muscular action alone, in the case of a man 60 years old, 
who, falling upon the left side, received an injury upon his right side. 
That an impacted fracture should have been thus produced seems to me 
scarcely credible. 

Rodet lias attempted to show by a series of experiments made upon 
the dead subject, and by other observations, that the direction in which 
the force had acted will determine the situation and direction of the frac- 
ture. Thus he maintains that when the person has fallen upon the foot 
or knee, the fracture will be intracapsular and oblique ; that if the front 
of the trochanter receives the blow, the fracture will be intracapsular 
also, but transverse; if the back of the trochanter is struck, the fracture 
will be partly intra- and partly extracapsular; and if the person falls 
directly upon the side, or receives the blow fairly upon the outer side of 
the trochanter, the fracture will be entirely without the capsule. 2 

Without intending to give my unqualified assent to these propositions 
so ingeniously maintained by Rodet, lam, nevertheless, prepared to admit 
their general accuracy; and especially has my experience led me to 
believe that falls upon the feet or knees in most cases produce intracap- 
sular fractures, and that falls upon the outside of the hip, or upon the 

1 Riedinger, Cent fur Chir., 1*7r,, No. 32, p. 817. 

2 L'Experience, March 14, 1844. 



4-22 



FRACTURES OF THE FEMUR. 



great trochanter, generally produce extracapsular fractures. There are, 
however, frequent exceptions to this latter proposition. Especially have 
I observed that in persons over fifty years of age, or somewhat advanced 
in life, a fall upon the trochanter has caused an intracapsular fracture. 
The following case, verified by an autopsy, is conclusive : 

A man, To years of age, was received at Bellevue, March 24, 18T5. 
He stared that on the same day he had slipped and fallen upon the side- 
walk, striking with great force upon the trochanter. The house surgeon 
Dr. E. A. Lewis, examined the limb immediately on admission, and 



Fig. 128. 



Pig. 129. 





Transverse intracapsular fracture. 



Intracapsular fracture caused by a fall 
upon the trochanter. 



diagnosticated an intracapsular fracture. I saw him during the day and 
confirmed the diagnosis. He was feeble, but not suffering much, ap- 
parently, from shock or from pain. Food and stimulants were adminis- 
tered, but no surgical treatment was adopted. On the following morning 
he was found to be sinking, and he died before night. After death 
Drs. Dennis and Isham repeated the manual examination, and found the 
evidences of an intracapsular fracture very marked, including a slight 
crepitus and rotation of the trochanter upon a short axis. The accom- 
panying woodcut, taken from the specimen now in the possession of Dr. 
Dennis, shows that the fracture was close to the head, and, of course, 
entirely intracapsular. It was not impacted, and no absorption of the 
neck had taken place. 

Pathology. — I have already, when speaking of partial fractures, ex- 
pressed my conviction of the possibility of a partial fracture, or a fissure 
of the neck of the femur, and I have referred to the case reported by 
Dr. J. B. S. Jackson, of Boston, as having determined this question 
beyond all possibility of a doubt; yet its occurrence must be regarded 
as an exceedingly rare, and, we may say, improbable event. 

It is much more common to meet with examples of complete fractures 
of the neck both within and without the capsule, unaccompanied with a 



NECK, WITHIN THE CAPSULE. 



423 



rupture of either the periosteum or the reflected capsule. Such was the 
fact in eight cases examined by Colles ; in three of which, however, he 
believed the fracture not to have been complete, but Robert Smith thinks 
they were all of them examples of complete fracture. 1 Stanley has also 
related a case of complete separation of the bone unaccompanied with 
laceration or injury of either the periosteum or capsular liagment. This 
was in the person of a man aged sixty years, who had been knocked 
down in the street. On being admitted into St. Bartholomew's Hos- 
pital, shortly after the injury, he complained of pain in the hip, but there 
was neither shortening nor eversion of the limb, and its several motions 
could be executed with freedom and power. A fracture was not sus- 
pected ; but five weeks after this he died of inflammation of the bowels. 
The dissection showed a fracture extending through the neck, accompa- 
nied with a slight bloody effusion, but no displacement of the fragments 
or laceration of the soft parts. 2 

In other examples the bone is not only broken, but displaced to such 
an extent that the capsule is completely torn in two. But in a large 
majority of cases both the capsule and the periosteum are only partially 
torn asunder. 

The intracapsular fracture is generally somewhat oblique, and its 
direction is usually from above downwards, and from within outwards. 
Sometimes its direction is such as to include a portion of the head ; oc- 
casionally it is quite transverse. Occasionally the intracapsular fracture 
is impacted. In one example of an old fracture I have seen the ends 
dovetailed upon each other, the fracture having a double obliquity, and 
not admitting of displacement. 

There may occur also another species of impaction, the lower portion 
of the neck entering the cancellous structure of the head, while its upper 
portion rides upon the articular surface, a 
circumstance which is well illustrated by 
the annexed woodcut (Fig. 130), copied by 
Mr. Smith from a specimen in the Dupuy- 
tren Museum at Paris ; or the impaction 
may occur without any degree of either up- 
ward or lateral displacement. 

Separation of the Epiphysis. — Mr. Lis- 
ten Bays : ''Even in children separation of 
the head of the bone may, on good grounds, 
be supposed occasionally to take place;" 3 
by which we understand him to mean that a 
separation of the epiphysis which completes 
the head of the femur may occur. Mr. 
South relates a case in a boy ten years of 
age. who had fallen out of a first-floor window 
upon his left hip. The limb was slightly 
turned out. bur scarcely at all shortened. 
The thigh could be readily moved in any direction without much pain, 
but on bending the limb and rotating it outwards, a very distinct dummy 

1 Colles, Dublin Hosp. Rep., vol. ii. p. 339. 

2 Stanley, Med.-Chir. Trans., vol. xiii. 

3 Listorl, Elements of Surgery, Phila. ed\, 1837, p. 480. 



Fig. 130. 




Impacted intracapsular fracture. 
(Smith.) 



424 FRACTURES OF THE FEMUR. 

sensation was frequently felt, apparently within the joint, as if one ar- 
ticular surface had slipped off another. This was regarded by Mr. 
South and Mr. Green as an example of epiphyseal separation, and he 
was placed upon a double-inclined plane, but he felt so little inconve- 
nience from it that he several times left his bed and walked about. We 
have no information as to the result or as to the further progress of the 
case. 1 According to Erichsen, M. Stanley reported a case in a lad of 18 
years. 

A girl, set. 18, was brought before Dr. Parker, of New York, at his 
surgical clinic, Nov. 1850, who had been injured by a fall upon a curb- 
stone, when eleven years old. The accident was followed by suppura- 
tion and a fistulous discharge, from which, however, she finally recovered, 
but with the foot everted, and a shortening of one inch and a half. 
"Flexion and rotation of the joint occasioned no inconvenience." Dr. 
Parker thought this circumstance alone sufficient to distinguish it from 
hip disease, in which anchylosis is the termination. 2 

At a meeting of the Kappa Lambda Society, held in New York, March 
25, 1840, Dr. Post mentioned a case which he had seen in a girl sixteen 
years old, who, in taking a slight step with a child in her arms, made a 
false movement, and feeling something give way, she was obliged to lean 
against a wall. Dr. Post saw her the next day, when he found the 
affected limb one inch shorter than the opposite one, movable, the toes 
turned outwards, no swelling, some slight pain at the upper part of the 
thigh. The trochanter major moved with the shaft. There was also 
crepitus. From the age of the patient, and the slight amount of violence 
by which the injury was produced, Dr. Post thought a separation of the 
epiphysis of the head had taken place. The extending apparatus was 
applied, but the limb remained from a quarter to half an inch shorter than 
its fellow. 3 

Aug. 14, 1865, Andrew Leroy, set. 15, in attempting to escape from 
the House of Refuge, fell from the fourth story. On # the following 
morning he was admitted into my wards, at Bellevue Hospital. I found 
his right thigh shortened three-quarters of an inch, and slightly ab- 
ducted ; toes everted. Placing him under the influence of chloroform, 
we detected a feeble crepitus in the vicinity of the joint. It was unlike 
the crepitus of broken bone. With fifteen pounds of extension we were 
able to overcome the shortening entirely, and to put the limb in position. 
This was maintained with Buck's apparatus. At the end of two weeks, 
however, it was ascertained to be shortened half an inch. Four more 
pounds were then added. At the close of my term of service I lost sight 
of the boy, and have not been able therefore to verify my diagnosis ; but 
I believe it to have been a separation of the upper epiphysis. 

Dr. H. Wardner, of Cairo, 111., has reported a case of "intracapsular 
fracture of the neck of the femur" in a boy fourteen years of age. 4 He 
does not state that he regarded it as epiphyseal, but his remarks lead us 

1 South, note to Chelius's Surgery, vol. i. p. 619. 

2 Parker, Amer. Med. Gazette, vol. i. p. 342, Nov. 30, 1850. 

3 Post, New York Journ. Med., vol iii. p. 190, July, 1840. 

4 Wardner, a paper read before the Southern Illinois Med. Assoc, at Arena, Illinois, 
June, 1877. 



NECK, WITHIN THE CAPSULE. 425 

to suppose that he did. The lad had hurt himself by jumping and alight- 
ing upon his feet, this being followed by a lameness in the hip-joint and 
some difficulty in walking. Twenty-four days later, on " attempting to 
get out of bed, one foot became entangled in the bedclothing, and this 
led him to exert forcibly the adductor muscles, when he suddenly cried 
out with pain, saying his hip had gone out of place, and he found him- 
self unable to rise. 

Dr. H. S. Smith, of Blandville, and Dr. Swett, being called, thought 
it a dislocation, and under chloroform attempted reduction, but unsuc- 
cessfully. Dr. Smith has since informed me by letter that he did not at 
that time detect crepitus. The day following Dr. Wardner was called, 
and in his report of the case he says the limb was shortened one or two 
inches, and was lying nearly parallel with the other limb, with the toes 
rotated. 

Dr. W. detected a "dull crepitation," and, regarding it as a fracture, 
made extension, and maintained it for several weeks, or until the cure 
was effected, when "the injured limb was of the same length as the sound 
one. and no deformity of any kind was detected." By a letter, however, 
dated February 2, 1875, thirteen months after the accident, from Dr. 
Smith. I am informed that there was then a shortening of one inch, and 

that the published statement of Dr. was derived from the father 

through Dr. Smith, and that he now found it to be incorrect. 

Dr. Smith farther states, " The motions of the hip-joint are limited to 
about one-half the normal extent, the muscles, leg, etc., of that side of 
the pelvis are considerably shrunken, he walks a little lame, and com- 
plains of weakness of the limb." . . . "I think there can be no 
doubt that the neck of the femur was fractured." 

It will be noticed that the first measurement was so indefinite that Dr. 
Wardner could only declare it "one or two inches" shortened; nor am 
I assured by Dr. Smith that the shortening observed by him was deter- 
mined by measurement, although I presume it was. 

Mr. Hutchinson 1 mentions three cases, and Spillman 2 refers to one 
observed by Sabatier, and another by Verduc. 

Only one case has been established by an autopsy. The subject of 
this accident, who was 15 years old, had been run over by a wagon. 
The limb was shortened and everted. The patient was unable to move 
the limb. He died in a few hours. There was found in the autopsic 
examination, complete separation of the epiphysis, which was attached 
to the neck by a strip of periosteum two millimetres in breadth. The 
capsule was torn at its inner portion. 3 

Dr. Stetter 4 has reported a case observed in a child 14 years old, and 
supposed by Professor Schonborn, of Konigsberg, to be caused by 
muscular action. The lad having slipped, threw himself backwards to 
himself, and fell on his left side. He experienced violent pain on 
the right side, and was unable to run. The right limb was found short- 
ened three centimetres, and strongly everted. No crepitus could be 

1 Hutchinson, lied. Times and Gaz., 1800, p. 196. 

Ilman, Die. Encyc. Art. Cuisse, p. 238. 
« Bullet, dela Societe A.nat., 1867, p. 283. 
* G. Stetter, Centralblatt furChir., 1877, No. 88, 9. 561. 



126 FRACTURES OF THE FEMUR. 

detected, but there was swelling in the region of the right trochanter, 
and the motion of the limb, produced by flexion caused intense pain. 

Symptoms. — (We are speaking now only of true fractures, having as 
yet no means of determining absolutely the symptoms of epiphyseal 
separations.) Whether the limb will be shortened or not must depend 
upon whether the fragments are impacted, or have become displaced in 
the direction of the axis of the shaft of the femur. It is well established 
that in this fracture the broken ends frequently remain in contact for 
several hours or days, or until the gradual contraction of the muscles or 
the weight of the body upon the limb occasions a separation, and that 
consequently there is often at first no appreciable or actual shortening of 
the limb. To determine, however, its existence, it is not sufficient to 
lay the patient upon his back and place the limbs beside each other; we 
ought also to measure carefully with a tape-line from the pelvis to the 
leg or foot, and from various other points, until we have placed this 
question beyond a doubt. 

If shortening occurs, it may vary from one-quarter of an inch to two 
inches, or even more ; but this extreme shortening is not reached usually, 
except after the lapse of several weeks or months, when the ligaments 
have gradually given way under the weight of the body in walking, or 
not until the neck has undergone a partial or almost complete absorption. 

Sir Astley Cooper has stated that a shortening to this degree may 
occur at once; but Boyer, Earle, and others, doubt the accuracy of this 
opinion, and Robert Smith declares that he does not think the capsule 
would admit of such an amount of immediate displacement, unless it 
were extensively torn, an occurrence which he thinks very rare indeed. 

With this qualification, the opinion of Mr. Smith does not differ from 
that entertained by Sir Astley, who only admits its possibility as a rare 
event; in a large majority of cases the shortening does not at first ex- 
ceed one inch. Of the methods of measurement, I shall speak hereafter, 
in connection with fractures of the shaft. 

Crepitus, unlike shortening, is generally absent when the displace- 
ment of the fragments is complete ; but under no circumstances is it 
easily developed. When the fragments remain in apposition, and the 
femur is rotated for the purpose of moving the broken surfaces upon 
each other, the small acetabular fragment, resting in a smooth cup-like 
socket, and holding upon the opposite fragment by denticulations or by 
the untorn periosteum, or capsule, glides about in obedience to the 
motions of this latter, and no crepitus can be produced. Nor is the 
difficulty rendered less by pressing firmly upon the trochanter, as some 
surgeons have recommended, since, while this pressure tends, no doubt, 
to fasten the upper fragment in the acetabulum, it tends much more to 
fasten the broken ends together, and thus defeats the purpose in view. 
When, on the other hand, the fragments have become completely separated, 
it is almost impossible to bring them again into contact. The limb may, 
perhaps, be easily brought down to the same length with the other, but 
it must by no means be inferred that, consequently, the broken ends are in 
apposition. It is almost certain, indeed, that in its progress downwards 
the trochanteric fragment has caught upon the acetabular fragment, and 
pushed its floating and broken extremity downwards before it. Under 
these circumstances, the discovery of a crepitus must be accidental, and 



NECK, WITHIN THE CAPSULE. 427 

is scarcely to be looked for. Sometimes, however, we may recognize a 
sound not unlike crepitus, but less harsh, produced by the friction of the 
trochanteric fragment against the rim of the acetabulum or dorsum of 
the ilium. 

One thing we ought never to forget, namely, that by extraordinary 
efforts to obtain a crepitus we may lacerate the capsule or produce a dis- 
placement of the fragments which we never can remedy, and which, 
without such unwarrantable manipulation, might never have occurred. 

Eversion of the foot is almost uniformly present in some degree, 
taking place immediately or more gradually, in proportion as the frag- 
ments become displaced, and the external rotators contract. The oppo- 
site condition, or an inversion of the foot, is occasionally present, and 
sometimes also the foot is neither turned in nor out, but the toes point 
directly forwards. In sixty cases of fracture of the neck seen by 
Cloquet the foot was never turned in, and Boyer never met with such an 
example in all of his immense experience ; but Langstaff, Guthrie, Stanley, 
Cruveilhier, Bigelow, Conklin, 1 have each seen one example, and Robert 
Smith has seen two. 2 I have myself seen one. 

The explanation of the fact that the foot is usually everted is not diffi- 
cult. In the case of an intracapsular fracture it is probably due, first, 
to the relative friability of the laminated or cortical structure on the pos- 
terior aspect of the neck, in consequence of which this portion gives way 
more readily than the cortical structure on the anterior aspect ; second, 
to the natural form and position of the foot and leg, which incline them 
to fall outwards by their own weight ; and, third, to the powerful action 
of the external rotators, which are so feebly antagonized upon the oppo- 
site side. 

In the case of an extracapsular impacted fracture, in addition to the 
second and third causes assigned as influencing the position of the limb 
in intracapsular fractures, there are other special causes. The cortical 
lamina on the posterior aspect of the neck, everywhere more frail than 
upon the anterior aspect, becomes greatly weakened as it approaches the 
trochanter by dividing itself into two laminae, one of which penetrates 
toward the centre of the bone, and the other, the thinnest of the two, 
being scarcely thicker than a sheet of paper, forming the wall of the bone 
as it becomes continuous with the trochanter. This delicate papery wall 
easily gives way under the application of force, while the anterior wall 
yields only partially, constituting thus a sort of hinge upon which the 
rotation of the thigh is performed. It is probable, also, as suggested by 
M. Robert, that the angle at which the external surface of the trochanter 
unites with the neck increases the tendency to fracture and impaction 
posteriorly. 

An explanation of the fact already stated, that in rare and exceptional 

the limb is inverted or the toes are permitted to point directly for- 

wards, has been thought to be more difficult. Dr. Bigelow has had an 

opportunity of examining a specimen taken from an old woman in the 

dissecting-room, and he; concludes that the inversion was due to the ex- 

1 "W. J. Conklin, Ohio, Columbus Med Journ., Nov. 1882. 

2 Robert Smith, op. cit., p. 25. A. Cooper by B. Cooper, op. oit., p. 151, note 



428 



FRACTURES OF THE FEMUR. 



tent of the comminution, which had separated the walls of the shaft so 
as to receive in the interval the whole neck, instead of the posterior wall 
only, as commonly occurs. Dr. Robert Smith, of Dublin, cites a similar 
ease verified by the autopsy ; and Dr. Bigelow remarks that the speci- 
men numbered 248 in the Mutter museum, at Philadelphia, presents the 
same kind of impaction without either inversion or eversion. 

Fracture of the neck of the femur within the capsule is not usually 
attended with much pain when the patient is at rest, but any attempt to 
move the limb produces intense suffering, and especially when an attempt 
is made to rotate the limb inwards, or to carry it upwards and inwards. 

Occasionally, also, during the first few days or hours after the frac- 
ture, a spasmodic action of the muscles compels the patient to cry out 



Fig. 131. 



Fig. 132. 





.#*' J 



Horizontal section of neck of femur. 
(From Bigelow.) 



Extracapsular fracture, with inversion. 
(From Bigelow.) 



from the severity of the pain which it produces. At first the sufferer 
is unable to indicate clearly the seat of this pain, or, perhaps, it is dif- 
fused and uncertain in its position ; but after a time he is able to refer 
it chiefly to the region of the groin, opposite the neck of the bone, or 
to near the point of attachment of the psoas magnus and iliacus internus. 



NECK, WITHIN THE CAPSULE. 429 

There is also usually in this region a great degree of tenderness and an 
unusual fulness. 

If now the limb be seized, and extension gradually but firmly applied, 
it will be soon made of the same length with the opposite thigh ; but, the 
moment the extension is discontinued, the shortening and eversion will 
recur, accompanied with pain, and perhaps crepitus. 

The trochanter major is less prominent than upon the opposite side, 
and if eversion of the limb exists, the trochanter may be felt indistinctly 
upwards and backwards from its usual position. The patient having 
been placed under the influence of an anaesthetic, we may prosecute the 
investigation still farther, and by rotating the limb inwards and outwards 
as far as it will admit, we shall notice that the trochanter describes the 
arc of a smaller circle than in the opposite limb, or that the length of 
its radius has been shortened. It ought to be said at once, however, 
that this amount of manipulation is often injurious, and seldom proper. 

The patient is generally unable to move his limb, or to bear the least 
weight upon it : but many examples are on record of persons who walked 
some distance after the fracture had taken place, the capsule, and per- 
haps also the periosteum, not being torn, and consequently the fragments 
not being displaced ; or, possibly,, it was at first an impacted fracture. 

On the 6th of May, 1875, Mrs. R., of Brooklyn, was ascending a 
flight of steps when her limb suddenly gave way under her, in conse- 
quence of an intracapsular fracture. Mrs. R. was 78 years of age, large, 
and rather fat. For several years she had suffered from rheumatism of 
the right leg, which compelled her, in walking, to bear her weight chiefly 
on the left, and it was this limb which gave way. She was assisted to 
her feet, and with the aid of her daughter ascended another flight of 
steps, bearing some weight on the broken leg. On the following day 
she got out of bed alone, and, unaided, walked a few steps, moving her 
limb very carefully. On the same day I saw her and found her in bed, 
the limb shortened half an inch and slightly everted. The head of the 
femur moved with the trochanter and without causing crepitus or pain. 
There was very little tenderness about the hip or groin; no swelling, 
and only a heavy, dull aching pain in the limb. The age, the manner 
of the accident, and the shortening of the limb were the only signs of 
fracture, but these were sufficient. 

Finally, after having examined the patient as well as we are able to 
do. in the recumbent posture, if any doubt remains, and it is found prac- 
ticable for the patient to be elevated upon his sound foot, this should be 
done. The broken limb can now be examined thoroughly on all sides, 
and a more accurate opinion formed of the amount of shortening and 
eversion. It will be especially noticed that if the weight of the body is 
allowed to rest upon the limb, in most cases it produces insupportable 
pain. 

M. Maisonneuve has lately suggested and practised the following 
method of diagnosis in certain doubtful cases: Lay the patient flat on 
his belly, and then bring the suspected thigh into extreme extension 
backwards. If it is not broken, the neck will strike against the pos- 
terior lip of the acetabulum and the progress of* the thigh in this 
direction will be arrested. If it is broken, it can be carried backwards 



430 FRACTURES OF THE FEMUR. 

much farther. 1 Of this method as a means of diagnosis, it seems proper 
to say that, if the fragments have slid past each other and the limb 
is shortened, it is unnecessary ; and if they are still in apposition, it 
will be pretty certain to cause displacement, and thus do irreparable 
mischief. 

Prognosis. — The question of bony union after a complete fracture of 
the neck of the femur within the capsule has occupied the attention of 
the ablest surgeons and pathologists for a long period ; and while great 
differences of opinion have been expressed as to the probability of the 
occurrence, and as to the value of the testimony on the one side or the 
other, very few have ventured to deny its possibility. 

Among these latter are found, however, the distinguished names of 
Cruveilhier Colles, Lonsdale, and Bransby Cooper. It has been re- 
peatedly affirmed, also, that Sir Astley Cooper taught the same doctrine, 
but with how much show of reason, the following paragraphs from his 
own pen will determine: 

" In the examinations which I have made of transverse fractures of the 
cervix fern oris, entirely within the capsular ligament, I have only met 
with one in which a bony union had taken place, or which did not admit 
of a motion of one bone upon the other. To deny the possibility of this 
union, and to maintain that no exception to the general rule can take 
place, would be presumptuous, especially when we consider the varieties 
of direction in which a fracture may occur, and the degree of violence 
by which it may have been produced. For example, when the fracture 
is through the head of the bone, with no separation of the fractured 
ends ; when the bone is broken without its periosteum being torn ; or 
when it is broken obliquely, partly within and partly externally to the 
capsular ligament, I believe that bony union may take place, although 
at the same time I am of opinion that such a favorable combination of 
circumstances is of very rare occurrence. Much trouble has been taken 
to impress the minds of the public with the false idea that I have denied 
the possibility of union of fracture of the neck of the thigh-bone, and, 
therefore, I beg at once to be understood to contend for the principle 
only, that I believe the reason that fractures of the neck of the thigh- 
bone do not unite, is that the ligamentous sheath and periosteum of the 
neck of the bone are torn through, that the bones are consequently drawn 
asunder by the muscles, and that there is a want of nourishment of the 
head of the bone; but I can readily believe, if a fracture should happen 
without the reflected ligament being torn, that as the nutrition would 
continue, the bone might unite ; but the character of the accident would 
differ; the nature of the injury could scarcely be discerned, and the 
patient's bones would unite with little attention on the part of the 
surgeon. 

"In proof of the correctness of my opinion, I enumerated, in the early 
editions of this work, forty-three specimens of this fracture, in different 
collections in London, which had not united by bone. At the present 
day these might be multiplied, were it necessary. 

1 Maisonneuve, Traitd du Diagnos. Malad. Chir., par Em. Foucher, torn. i. prem. 
part. p. 287. 



NECK, WITHIN THE CAPSULE. 431 

"Such has been the accumulated evidence of the want of power of the 
neck of the femur to unite by bone, in rny practice for forty years, during 
which period I have seen but two or three cases which militate against 
this opinion, for many of the preparations which have been brought for 
my inspection as specimens of united fractures of this part have proved 
to be nothing more than the result of the changes concomitant with old 
age: and in many of them the two thigh-bones of the same subject had 
undergone the same alteration in texture and in form.'" 1 

The following passages from a communication made by Sir Astley to 
the London Medical Gazette, for the :25th of April. 1834, are equally 
pertinent : 

"I find in a report of the Baron Dupuytren's lecture that he attrib- 
utes to me the opinion that fractures of the neck of the thigh-bone, within 
the capsular ligament, not only 'never unite, but that it is impossible 
that they should unite by bone." 

**It is quite true that, as a general principle. I believe that those frac- 
tures unite by ligament, and not by bone, as do those of the patella and 
olecranon. ■ But I deny that I have ever stated the impossibility of their 
ossific union : on the contrary. I have given the reason why they may 
occasionally unite by bone. 

•• The following are my words : * To deny the possibility of their union, 
and to maintain that no exception to this general rule may take place. 
would be presumptuous.' " etc. etc. 

In conclusion. Sir Astley remarks : " I should not have given you 
this trouble, nor should I have taken it myself, but for the respect I 
bear my friend, the Baron Dupuytren : for although I have already sub- 
mitted myself to be misrepresented by many individuals, yet I should be 
sorry to be misunderstood by so excellent a surgeon and so valuable a 
friend as Le Baron Dupuytren. "- 

Sir Astley. then, so far from denying, frankly admitted the possibility 
of bony union when the neck was broken within the capsule, and ex- 
plained the circumstances under which he believed it might occur. The 
true point in dispute was, whether certain cabinet specimens were actually 
examples of complete fractures, wholly within the capsule, united by 
bone. Some of them Sir Astley thought were only examples of chronic 
rheumatic arthritis, or of interstitial and progressive absorption. Some 
were partial rather than complete fractures : others were partly within 
and partly without the capsule; and for this he was accused of wilful 
blin-ii. 9fi stupidity, chiefly by those who. themselves being owners of 
rare pathological treasure-, might possibly have felt somewhat 
anil- ■ - !n f their value thus depreciated, and who. no doubt, would 

be quite as apt to fall into blindness and partisanship a- Sir Astley him- 
self. The truth is. however, that although the claim has been set up and 
tly maintained for more than thirty cabinet specimens, in one part of 
the world or another, a majority of these, including several whose claims 

the Joints, edited by Bransby 

... p l •"»•;. 

- - \, written in 1835, ami published in the 

Pr<>v. Med. and Surg-. Journ. for July 12. 1-1-: New York .J-'urn. MecL for 
nd appendix Dis. and Fruc.. A hut. ed., 1851, 



432 FRACTURES OF THE FEMUR. 

were urged upon Sir Astley, have been at length declared by all parties 
unsatisfactory, or absolutely fictitious, and only a fraction of the whole 
number continue to be mentioned by any surgical writer as probable 
examples. 1 

Robert Smith reduces the number to seven, but Malgaigne recognizes 
only three, namely: Swan's case, admitted by Sir Astley himself; 
Stanley's case, and one specimen in the Dupuytren museum. In neither 
of these cases, he affirms, has the neck lost anything of its form or 
length by absorption, from which we are to infer that he would reject as 
doubtful all such specimens as had undergone these pathological changes. 

Indeed, I think, we are not left in doubt as to Malgaigne's opinion 
upon this point. Six of the nineteen cases which I have enumerated 
are declared by him to resemble much more rachitic alterations of the 
neck than true fractures ; and yet Robert Smith admits three of the six 
as well-established examples ; but as to the precise grounds upon which 
he rejects these cases, he shall speak for himself: "And it is sufficient 
that we consider the beautiful drawings designed by Sir Astley Cooper, 
to illustrate certain varieties of the alterations, to place us on our guard 
against every pretended consolidation which presents itself, accompanied 
with a shortening and deformity of the head and neck. When fractures 
unite by bone, they do not suffer such enormous losses of substance 
which it would become necessary to admit for the neck of the femur." 2 

A reference to Stanley's case, as reported by Robert Smith, will 
show that, contrary to Malgaigne's statement, this was also shortened 
and deformed, and that, consequently, according to his own rules of 
exclusion, it also must be rejected ; after which only two remain, 
namely, Swan's case, admitted by Sir Astley himself, and No. 188 of 
the Dupuytren museum. 

I should do injustice to my own convictions, moreover, were I not to 
refer my readers to the very judicious criticism upon Mr. Swan's case 
made by Dr. Johnson, and published in the New York Journal of 
Medicine, vol. ii. 3d series, p. 295. 

Since writing the above, my friend Dr. Voss, of this city, has placed 
in my hands an elaborate paper on this subject, from the pen of Dr. 
Edward Zeiss, of Dresden, and which has been translated by Dr. R. 

1 The following European surgeons have claimed to have in their possession, each, 
one example: Langstaff (Med.-Chir. Trans., vol. xiii. 1827); Brulatour (Ibid., vol. 
xiii., 1827); Stanley (Ibid., xviii.) ; Swan (Swan on Diseases of Nerves, p. 304); 
Adams (Todd's Cyclop., p 813); Jones (Med.-Chir Trans., vol. xxiv.) ; Chorley 
(Amesbury on Frac. p. 125) ; Field (Ibid., p. 128) ; Soemmering (Chelius's Surgery 
by South, vol. i. p. 621) ; South (Ibid., p. 621). South also mentions another exam- 
ple as being in the museum of St. Bartholomew's Hospital. This is probably Jones's 
case, which Robert Smith says is pieserved in this museum, and which has already 
been enumerated. Bryant (Memphis Med. Rec, vol. vi. p. 108, from British Med. 
Journ., March 14) ; Fawcington ( Amer. Journ. Med. Sci., vol. xv. p. 534, from Lon- 
don Med. Gaz., Aug. 16, 1834) ; Harris (Ibid., vol. xviii. p. 246, from Dublin Journ., 
Sept. 1835). Robert Hamilton says that Prof. Tilanus showed him three specimens 
in the museum of the Hospital of St. Peter, at Amsterdam (Ibid., vol. xxxi. 470, from 
Lond. Mod. Gaz., Jan. 6, 1843). Malgaigne says there are three specimens in the 
Dupuytren museum which have been described with the same interpretation. The 
whole number claimed by transatlantic surgeons is therefore nineteen. 

2 Malgaigne, Traite des Fractures et des Luxations, torn. i. p. 678. 



NECK, WITHIN THE CAPSULE. 433 

Newman, Prosector to Chair of Surgery, Long Island College Hospital. 
Dr. Zeiss, after rejecting all other European specimens, claims that bony 
union has occurred within the capsule in a specimen now in his posses- 
sion, and also in a specimen which may be found in the pathological 
cabinet of the Medico-chirurgical Academy of Dresden. 1 I regret that I 
am not able to publish these cases at length, as well, also, as the able 
review of their claims sent to me by Dr. Newman, in which Dr. Newman 
clearly shows that Dr. Zeiss has completely failed to establish the cor- 
rectness of his opinions. There is no conclusive evidence that the bones 
were ever broken, nor, if they were broken, that the fractures were 
entirely within the capsule. 

On this side of the Atlantic, the number of specimens for which the 
honor is claimed is nearly equal to the original number in Europe ; but 
they have not yet, all of them, been subjected to the same sifting process 
as their foreign congeners : and it remains to be seen how many of them 
will come successfully out of a similar fifty years' contest. 

Three of the specimens belonged to Reuben D. Mussey, late Professor 
of Surgery in the Miami Medical College, at Cincinnati, Ohio. He has 
himself furnished a complete history and description of the specimens, 
accompanied with drawings. 2 One may be found in the Wistar and 
Horner Museum at Philadelphia; 3 one belongs to Willard Parker of 
this city : 4 two to the Albany College Museum ; 5 two to the Harvard 
Medical College, Boston ; 6 one to the Mutter collection (Specimen B, 
71) ; one to Dr. Pope, of St. Louis. Dr. Sands, of this city, has lately 
presented a supposed example to the New York Pathological Society. 7 
Dr. Adler has presented one to the College of Physicians of Philadel- 
phia. 8 

I will add that Dr. Packard, of Philadelphia, has published an excel- 
lent critical notice of most or all of the published cases, and suggests 
that they all admit of the following explanation : The fractures were 
actually extracapsular ; but, after union took place, that portion of the 
neck attached to the head underwent absorption, until the head was 
brought into contact with the trochanters. 9 

In three editions of this book I have examined the claims of several of 
these specimens very much at length ; but as new specimens are every 
now and then being presented to our notice, for each of which special 
claims are set up, and inasmuch as no practical results are likely to follow 
upon a further discussion of this point, or upon its definite decision, I 
have concluded to refer those of my readers who feel a particular interest 
in the matter to either one of my earlier editions, and to the various 
monographs to which I have furnished references. 

1 Description of two .specimens of intracapsular fractures of the neck of the femur, 
and union by callus, by Dr. Edward Zeiss, Dresden, 1864. 

2 Amer. Joum. Med. Sci., April, 1857. 

3 H. H. Smith'. Surgery, p. 399. 

4 Johnson'.- paper on Intracapsular Fractures, op. cit. 

5 Tram. New York Stat- Med. Boc., 1858. 

6 Bigelow on Dislocation, etc . of Hi],, 1869, p. 125. 

7 New York Med. Bee., June 1,18 

• Am. Journ. Med. Sci., April, 1870. 
9 Ibid., Oct. 1*67. 

28 



434 



FRACTURES OF THE FEMUR. 



I have also in my own cabinet a femur of no inconsiderable preten- 
sions, belonging clearly to that class of specimens recognized by Robert 
Smith. Its neck is greatly shortened, and this surgeon would regard it, 
I think, as an impacted intracapsular fracture, but its claim would be 
promptly denied by Malgaigne, on account of the absorption and dis- 
tortion of its neck. Its history is as follows : 

About the year 1833, Mrs. Wakelee, of Clarence, Erie County, New 
York, set. 68, who was then very low with tubercular consumption, and 
so ill as to be scarcely able to walk across the floor, tripped upon the 
carpet and fell, striking upon her left side. She was unable to rise, but 
w r as laid upon a bed by her son, Dr. Wakelee, a very intelligent physician, 
residing in the same house, who did not suspect a fracture. Dr. Bissel 
saw her on the following day, and, on rotating the limb outwards, he says 
that he discovered a crepitus. His examination was greatly facilitated 
by her extreme emaciation. 

Mrs. W. was placed upon a double-inclined plane, with apparatus for 
extension, etc., and left in charge of Dr. Wakelee. On the fifth day the 



Fig. 133. 



Fig. 134. 





Vertical section of Mrs. Wakelee's 
femur, acetabulum, and capsule. 



Impacted fracture within the capsule. (From 

Bigelow.) 



splint was removed, and from this time no dressings of any kind were ap- 
plied. The reason for this change of treatment was, that she was likely 
to live but a few days, in consequence of the state of her lungs, and that 
such confinement would only hasten her death. Contrary, however, to 
all expectations, she gradually convalesced, so that after two or three 



NECK. WITHIN THE CAPSULE. 435 

years she could walk on crutches, her toes turning out and her limb 
becoming somewhat shortened. Four years after the accident she died, 
and Dr. Bissel obtained from Dr. Wakelee the specimen, of which the 
accompanying drawing is a faithful delineation. 

Dr. George K. Smith, of the Long Island College Hospital, has made 
a most valuable contribution to our knowledge of the anatomy and 
pathology of the hip-joint, which will explain in a great measure the 
discrepancies of opinion which at present exist among surgeons as to the 
character of certain specimens, and may hereafter enable us to decide 
with more accuracy, and may lead to a better agreement of opinion. 

His observations prove that anatomists have not hitherto correctly 
described the attachment of the capsule ; that the capsule is seldom, if 
ever, attached at the same point in different persons, while it is as uni- 
formly found attached at the same point in the opposite femurs of the 
same person. In order, therefore, to determine whether the line of frac- 
ture in any given specimen was without or within the capsule, we must 
always compare the fractured bone with its congener, and not with 
the femur of another person. 

He has further shown that after a fracture, and the consequent ab- 
sorption of the neck, the normal position of the capsule is almost con- 
stantly changed ; so that its present attachment does not declare what 
were the points of its attachment before the fracture occurred ; and, 
finally, that the absorption proceeds unequally and irregularly, yet with 
great rapidity, in the two fragments ; and as the bony union, if it 
ever takes place, probably occurs subsequent to the arrest of the ab- 
sorption, the line of union cannot in itself alone determine whether the 
fracture was near the head or near the trochanters. 1 

It <eems to me probable that under certain favorable circumstances 
this union will occur : these favorable circumstances have relation to 
several conditions, such as age, health, degree of separation of the frag- 
ments, whether impacted or not, laceration of the periosteum and cap- 
sule, treatment, etc. Robert Smith thinks it is not likely to occur unless 
the fragments are impacted ; but Sir Astley Cooper, as we have already 
seen, admitted its possibility whenever the reflected capsule and the peri- 
osteum were not torn, and at the same time the fragments were not 
displaced. If to these conditions we were to add moderate but not ex- 
treme aire, with good health, we can see no sufficient reason why, under 
judicious treatment, bony union might not occasionally be expected. But 
Bach a combination of circumstances is probably exceedingly rare; and, 
what is more unfortunate, if they exist, the fracture is not likely to be 
recognized, and the surgeon will fail to avail himself of those advan- 
tageous coincidences which might, if understood and properly treated, 
secure a bony union. Dupuytren says, when the fragments are not dis- 
placed ,; its existence may be suspected, but cannot be positively asserted." 
There will not be wanting, however, examples in which surgeons will 
believe or affirm that they have recognized the fracture and wrought the 
cure. I have heard of many such instances, and Mr. Smith has referred 

1 George K. Smith. Insertion of the capsular ligament of the hip-joint, and it- rela- 
tion to intracapsular fracture. Medical and Surgical Reporter, Philadelphia, 1862. 



436 



FRACTURES OF THE FEMUR. 



to one, which is quite pertinent, as having been reported in the Gazette 
des Hopitaux. A woman, aet. 64, was treated for an intracapsular frac- 
ture of the neck of the femur at one of the hospitals in Paris, and 
•• at the end of four weeks she was discharged perfectly cured, and with- 
out shortening." We fully partake of Mr. Smith's surprise at the impu- 
dence of this claim, yet we do not see in it much greater improbability 
than in Mr. Swan's case, received by both Mr. Smith and Sir Astley 
himself, where the neck was found almost wholly united by bone in five 
weeks, although the woman was eighty years old, and actually dying 
while the process was going on ! Says Dupuytren, " I would lay it down 
as a general principle that all fractures of the neck of a cylindrical bone 
should be kept at rest twice as long as ordinary fractures of the same 
bone; and even after that period I have seen displacement take place. 
The term may, therefore, be lengthened to a hundred days, or even 
longer in aged and feeble persons, whose powers of reparation are much 
deteriorated." 

It is not the purpose of the writer to describe particularly all of the 
accidents or pathological conditions with which these fractures may be 
confounded. It is sufficient to allude to them, and leave to others the 
labor of a complete historical record ; but I am tempted to devote a 
paragraph to what has been variously termed "morbus coxae senilis" 
(Robert Smith); "chronic rheumatic arthritis" (Adams); "interstitial 
absorption of the neck of the thigh-bone" (B. Bell); "rheumatic gout" 
(Fuller); and by others "dry arthritis" "interstitial and progressive 
absorption ;" but the exact nature and cause of which morbid changes are 
not yet fully understood. Mr. Colles does not think this partakes of the 
nature of rheumatism. I have myself a specimen of what has been more 
generally called chronic rheumatic arthritis, occurring in the knee-joint, 
accompanied with a flattening and eburnation of the articular surfaces, 

and Gulliver has shown that similar 
changes of form in the neck of the bone 
may occur in tolerably young persons. 

I suspect also that it will be found 
to occur under a great variety of cir- 
cumstances, and to present a greater 
variety of forms than have yet been de- 
scribed; and we shall, perhaps, find a 
partial explanation of this diversity and 
frequency in one single circumstance, 
namely, the peculiar anatomical structure 
of the neck. The neck of the femur 
stands nearly at a right angle with the 
shaft, or at an angle so great as that the 
weight of the body, even in health, has 
the effect to depress gradually the head 
below the top of the trochanter major, 
and to diminish its length. This is seen 
constantly in the striking change of form 
which occurs between childhood and old age. Now, if from any cause 
whatever, such as a blow upon the trochanter or upon the foot, the 



Fig. 135. 




Section of a sound adult femur. 



NECK, WITHIX THE CAPSULE. 



437 



neck or head is made to suffer ; and inflammation, or, perhaps, only 
a slight degree of increased action in the absorbents, ensues, resulting in 
an equally slight softening of the bony tissue, these pathological cir- 
cumstances may end. sooner or later, in a striking change of form in 
the neck or head. But it is not necessary to suppose an external injury 
to explain the occurrence of this inflammation, and consequent softening 
of the bone : a scrofulous, or rickety, or tuberculous constitution may 
occasion it. and we see no reason why these conditions are not as likely 
to lead to a change of form here as in the bones of the leg or of the spine. 
A change of form in the head may be the result of an ulceration of the 
cartilage: and a change of form in the neck, of ulceration of the neck. 
Among other causes, also, "chronic rheumatic arthritis" may operate 
in a large proportion of those examples which belong to advanced life. 
One case, reported Gulliver, would seem to show that a deformity may 
occur here as a result of disease, and independently of pressure, 1 yet it 
is plain, froru the direction which the deviation of the head and neek 
usually takes, that pressure performs an important part in the causation. 
From these various causes, operating in these diverse ways, we shall 
have the different deformities enumerated and described by surgical 
writers. The head flattened, irregularly spread out. depressed, and 

Fig. 136. 




Chronic rheumatic arthritis. (Miller.) 

polished; the neck shortened and irregularly thickened and expanded ; 
the trochanter major rotated outwards and drawn upwards; sinuous 
chasms traversing the neck, produced by ulceration: and finally, short- 
ening of the Deck, by a true interstitial absorption, and with little or no 
increase in it- breadth, the trochanter major also being rotated outwards. 
It would be strange, moreover, if the interior of these bones did not 

1 Gulliver. Lond. Med.-Chir. Bey., vol. mix. p. 544. 



438 FRACTURES OF THE FEMUR. 

present some changes in structure, such as have been frequently ob- 
served, namely, an irregular expansion or condensation of the cellular 
tissue, and which latter might easily be supposed, by one who was inat- 
tentive to all of these circumstances, to indicate the line of an imaginary 
fracture. 

The following example will illustrate the incipient stage of one class 
of these eases, namely, that in which the neck is not only shortened, but 
its surface is irregularly seamed, as if it had been broken and imperfectly 
united : 

William Clarkson, aet. 43, was admitted into the Toronto Hospital, 
C. W., May 5, 1858, with tubercular consumption, of which he died on 
the 25th of the same month. 

He had been under the care of Dr. Scott, and it having been noticed 
that he complained of his right hip at the time of admission, an autopsy 
was made on the 25th, at which I was, through the courtesy of the house 
surgeon, permitted to be present. 

We examined both hip-joints, and found the neck of the right femur 
shortened, especially in its posterior aspect. At the junction of the 
head with the neck, posteriorly, and extending about half-way around, 
the bone was carious, and so far absorbed as to leave a sulcus of a line 
or two in depth, and of about the same width. Adjacent to this, also, 
the bone was quite soft, yielding under the slightest pressure of the 
knife. There was no other appearance of disease. The opposite femur 
was sound. 

The hospital record furnished the following account of his case, so far 
as the injury to his hip was concerned : 

About nine months before admission, then laboring under the malady 
of which he finally died, he received a blow upon his right trochanter, 
ever since w 7 hich he had been lame, and suffered pain in the region of 
the hip-joint. The pain was felt especially in the groin, when the tro- 
chanter was pressed upon, or when the sole of his foot was percussed. 
The thigh was slightly flexed ; the toes a little everted ; and he walked 
with some halt. 

The case of the soldier, Fox, reported by Gulliver, and who died of 
tuberculosis, presents a case also exactly in point, but illustrating a later 
stage, or the completion of the same process. 

Of the precise nature of the changes in the two following examples 
I cannot be certain, since they have not been determined by dissection. 
They will serve, however, to illustrate the usual history and progress of 
a considerable Dumber of cases. They certainly w r ere not examples of 
fracture. 

Ephraim Brown, when twelve years old, fell from a tree and struck 
upon his right foot. Dr. Silas Holmes, of Stonington, Ct., was called. 
Of the particular symptoms at this time, I have only learned that the 
leg was not shortened. The doctor laid a plaster upon his hip, and left 
him without any further treatment. In three days he was able to walk 
on crutches; in three weeks he walked without crutches, and in four 
months was at work as usual. There was at this time no shortening or 
deformity of any kind. 

Mr. Brown subsequently enlisted as a soldier in the war of the 



NECK, WITHIN THE CAPSULE. 439 

American Revolution, and experienced no difficulty in his hip, until 
after a severe illness which followed upon an unusual exposure, when 
he was about thirty-five years old. At this period the leg began to 
shorten, but the shortening was unaccompanied with pain or soreness. 

He consulted me, July 17, 1845, at which time he was eighty-three 
years old, and a remarkably strong and healthy-looking man. The 
shortening, which had ceased to progress some years before, amounted 
at this time to two and a half inches. 

An officer in the United States army addressed to me the following 
letter, dated November 13, 1849: 

"My mother-in-law, Mrs. S., of D., some three years since fell down 
a flight of stairs, striking on her side upon a stone, injuring the hip- 
joint severely ; but, upon examination, her physician declared that 
there was neither a fracture nor a dislocation, and said that she would 
gradually recover. Something like one year since, the injured limb 
commenced shortening, so that she can now barely touch her toe to the 
floor as she walks. She can bear but little weight upon it and is com- 
pelled to use a crutch or a cane constantly. So much time has now 
elapsed, and the limb is so little better, and constantly becoming shorter, 
I have proposed to ask your opinion," etc. 

I need scarcely say that I had no hesitation in pronouncing this a case 
of chronic inflammation of the bone, accompanied with softening and 
gradual change of form, either of the neck or head, or of both. 

It is proper that I should state briefly, before I leave this subject, 
what constitute the chief difficulties in the way of union by bone within 
the capsule. 

The persons to whom the accident occurs are generally advanced in 
life, and consequently the process of repair is feeble and slow. 

The head of the bone receives its supply of blood chiefly through the 
neck and reflected capsule, and, when both are severed, the small amount 
furnished by the round ligament is found to be insufficient. 

When the fragments are once displaced, it is difficult, as I have already 
explained, if not impossible, to replace them. 

The direction of the fracture is generally such, that the ends of the 
fragments do not properly support and sustain each other when they are 
in apposition. 

The fracture is at a point where the most powerful muscles of the 
body, acting with great advantage, tend to displace the broken ends. 

Aged persons, who are chiefly the subjects of this accident, do not 
bear well the necessary confinement, and especially as the union requires 
generally a longer time than the union of any other fracture; so that a 
persistence in the attempt to routine the patient the requisite time often 
causes <l<;tth. 

In all cases in which any degree of displacemenl exists, excepl it be in 
the direction of impaction, the ends of the broken fragments are con- 
stantly bathed with the synovia] fluid, which musl be increased by the 
inflammation resulting from the fracture. Consequently, whatever repa- 
rative bony material is famished by the broken surfaces musl !><■ lost, 
rendering bony union, or even fibrous union from tins source impossible. 

Lastlv. there is never found in these intracapsular fractures anything 



440 



FRACTURES OF THE FEMUR. 



like provisional callus ; and whatever useful purpose it may serve in other 
fractures, it certainly renders no aid here. 

It remains only to consider what are the most common results of this 
fracture. 

The fragments, more or less displaced, undergo various changes. The 
acetabular fragment is generally rapidly absorbed as far as the head ; 
and occasionally a considerable portion of this latter disappears also ; 
while the trochanteric fragment appears rather as if it had been flattened 
out by pressure and friction, it having gained as much generally in 
thickness as it has lost in length. To this observation, however, there 
will be found many exceptions. Sometimes the trochanteric fragment 
forms an open, shallow socket, into which the acetabular fragment is 
received ; or its extremity may be irregularly convex and concave, to 
correspond with an exactly opposite condition of the acetabular fragment. 
(Fig. 137.) 

Ordinarily the two fragments move upon each other, without the 
intervention of any substance ; but often they become united, more or 



Fig. 137. 



Fig. 138. 





Intracapsular fracture. Ununited. Op- 
posite surfaces irregularly convex and con- 
cave, and polished; moving slightly upon 
each other. (From a specimen in the pos- 
session of Dr. Josiah Crosby.) 



Mayo's specimen. United by ligament. 
Patient lived nine months after the accident. 
The trochanter minor arrested the descent 
of the head. (From Sir A. Cooper.) 



less completely, by fibrous bands (Fig. 133), which bands may be short 
or long, according to the amount of motion which has been maintained 
between the fragments while they are forming, or to the degree of sepa- 
ration which exists. 

The capsular ligaments are usually considerably thickened, and elon- 
gated in certain directions, and not unfrequently penetrated by spicula 



NECK, WITHIN THE CAPSULE. 



441 



of bone. They are also found sometimes attached by firm bands to the 
acetabular fragment. 

A permanent shortening is the invariable result of this accident ; and 
a few succumb rapidly to the injury, perishing from a low, irritative 
fever, or from gradual exhaustion, within a month or two from the time 
of its occurrence. Says Robert Smith : " Our prognosis, in cases of 
fracture of the neck of the femur, must always be unfavorable. In many 
instances the injury soon proves fatal, and in all the functions of the limb 
are forever impaired ; no matter whether the fracture has taken place 
within or external to the capsule — whether it has united by ligament or 
bone — shortening of the limb and lameness are the inevitable results." 

Dr. Frederick E. Hyde, of this city, has made a very careful exami- 
nation of twenty cases of fracture of the neck of the femur, after several 
years from the date of the fracture. Thirteen of these had been diag- 
nosticated as intracapsular, and seven as extracapsular. All were short- 
ened : the shortening ranging from three-eighths of an inch to two and a 
quarter inches in the intracapsular fractures ; and from one-quarter to 
one and a half inches in the extracapsular. 

Some of the cases had never been treated by apparatus of any kind, and 
it was observed that, omitting one case in which the contracted position 
of the limb did not permit an accurate measurement, the average shorten- 
ing was one and three-eighths of an inch ; while in those which had been 
treated as fractures, the average shortening was about one inch. All, 
or nearly all of them were still suffering with more or less pain and stiff- 
ness about the joint, and walked with a manifest halt. 1 

Treatment. — In case, then, of a complete fracture within the capsule, 
existing without laceration of the reflected capsule, or displacement of 



Fig. 139. 




Author's apparatus for fractures of the neck of the femur. 



tie- fragments, and equally in case of a fracture at the same point with 
impaction, the treatment ought to be directed to the retention of the bone 
in place, by suitable mechanical means, for a length of time sufficient to 
insure bony union, or for bo long a time as the condition of the patienl 
will warrant. 

The means which are, in my judgment, best calculated to fulfil this im- 
portant indication, are complete rest in the horizontal posture, the limb 
being secured by the same apparatus which we employ with bo much buc- 



1 Hyde. Deformity after Fracture of the Neck of the Femur; 20 easi 
and tabulated. Med. Gazette, April 17. 1880, p. 244 



nged 



44:2 



FRACTURES OF THE FEMUR. 



cess in fractures of the shaft. In fractures of the neck, however, whether 
within or without the capsule, we employ no coaptation splints; and the 
amounl of extension ought to be only one-half of that generally employed 
in fracture of the shaft, say about ten pounds. The long side-splint, 
with a foot-board, to prevent eversion of the limb, must not be omitted. 
In my hands, the apparatus has undergone so many modifications from 
the original plans of Crosby and Buck, that I shall hereafter find it 
necessary to designate it as my own. 

Fig. 140. 



ti^h- - 



: ^^3MlMiMM. 




Gibson's modification of Hagedoxn's splint. 

Another apparatus, formerly employed by me in fracture i of the neck 
of the femur, but for which I have substituted my own, is Gibson's modi- 
fication of Hagedorn's, in which the sound limb is first secured to the 
foot-board, and the broken limb is subsequently brought down to the 
same point. By this method, as by my own apparatus, we may avoid 
the necessity of a perineal band, which is so painful, insupportable often 
when the fracture is at the neck. 

In treating this fracture, supposing no displacement to exist, no exten- 
sion beyond that which is necessary to insure perfect quiet can be proper, 
inasmuch as the fragments are not overlapped; and they need only a 
moderate assistance to enable them to maintain their present position 
against the action of the muscles. Moreover, if the fragments are im- 

Fig. 141. 




Gibson's modified splint applied. 

pacted, violent extension would disengage them, and render their dis- 
placement and non-union inevitable. 

I am prepared to affirm, from my own experience, that more patients 
will endure quietly the position of extension for a length of time than the 
flexed position, whether in this latter the patient is placed upon his side 
or upon his back. 

How long the patient will submit to this, or to any other mode of 
securing perfect rest, is very uncertain, and the decision of this question 



NECK, WITHIN THE CAPSULE. 443 

must rest with the individual cases and the good sense of the surgeon. 
Not verv many old and feeble people will bear such confinement many 
days without presenting such palpable signs of failure as to demand their 
complete abandonment. 

Horizontal extension was adopted in Jones's case, and also in the case 
reported by Fawdington, and is said to have been successful. In Bru- 
latour's case the limb was kept extended two months ; in Mussey's 
second case Hartshorne's straight splint for extension remained upon 
the limb eighty-four days; in Bryant's case a long splint was used 
" some weeks." 

It is true, however, that other plans of treatment seem to have been 
equally successful. In the case reported by Adams the limb was placed 
over a double-inclined plane, made of pillows, five weeks ; and in Mus- 
sey's third example the limb remained in the same position three months. 
Chorley laid his patient upon the sound side, with the thighs flexed, for 
a space of two weeks, and then turned him upon his back, still keeping 
the thighs flexed. At the end of six weeks he was placed in a straight 
position. 

But in a majority of the examples reported, the existence of the frac- 
ture was either not suspected, or bony union was not anticipated or de- 
sired, consequently no treatment having in view the confinement of the 
broken bone was adopted. Yet the success, it was claimed, was as great 
as that which lias followed either of the other plans. Harris's patient 
was simply laid on a sofa. Field's patient, who broke the neck of both 
femurs within the capsule at different times, was in each case left with- 
out treatment, except that she lay upon her bed. Mussey himself re- 
moved all dressings from Dr. Dalton's patient on the eighteenth day, and 
placed him upon his feet, and Dr. Wakelee removed the apparatus from 
his mother on the fifth day. 

Nor are we without evidence that the careful and judicious applica- 
tion of splints, long continued, and employed under the most favorable 
circumstances, will sometimes fail. The two following casts confirm 
these remarks. The first occurred in the practice of Dr. James R. 
Wood, of this city: "M. J., a young lady, ret. 16 years, of vigorous 
constitution, perfectly free from any constitutional taint, either of scrofula, 
syphilis, or cancer, was caught between the wheels of two carriages, the 
'■no stationary, the other in motion. The blow was received directly on 
the trochanter major of the right side. The symptoms which presented 
themselves showed conclusively that there was a fracture. Tli ere were 
shortening, loss of voluntary motion, and eversion : by placing the finger 
on the trochanter major, and the thumb on the groin, a well-marked 
crepitus could be felt en extension and rotation being made. There was 
no laceration or other complication of the injury. She was placed on 
Amesbury'g splint, with Bide-splints accurately adjusted, and cxery pre- 
caution token to insure ;i perfect union. Tlio limb was kepi on tins 
splint without being disturbed for Bis weeks. At the end of thai time 
it was taken from the splint, and examined with care; the signs of frae- 
ture -till remained. The limb was replaced on the splint, and the 
dressings applied ;i- before; everything was attended to in the general 
management of the case which the doctor thought would be conducive 



444 FRACTURES OF THE FEMUR. 

to perfect union. The patient was kept for three weeks longer on the 
splint, which was then removed. It was found that there was no union. 
Patient lived for three years, and was so lame that she was always 
obliged to use a crutch in walking. At the expiration of three years 
she died of an acute disease. 

" On examination of the cervix femoris, it was found that there had 
been a transverse fracture of the bone just at the junction of the head 
and neck. The head of the bone was still attached to the acetabulum 
by the ligamentum teres. The process of absorption had been going on, 
and the head of the bone had already been absorbed below the level of 
the acetabulum, and what remained was soft and spongy, easily broken 
with the handle of the scalpel. The neck of the bone was rounded off, 
and covered with a fibrous deposit. This was not a case of diastasis, as 
has been suggested by an eminent surgeon, who judged simply from the 
age of the patient. She was full sixteen when the accident happened 
and over nineteen wdien she died." 

The second was in the person of a man, set. 25 years, who was at the 
time of the accident robust and in good health. "He was dancing at 
his sister's wadding; w T hile cutting a pigeon-wing, he struck the foot 
upon which he was resting from under him, and fell, striking directly 
upon the trochanter major. He was unable to rise ; a carriage was 
called, and he was taken directly to the New York Hospital. There he 
came under the charge of Dr. J. Kearney Rodgers. A fracture was 
immediately diagnosticated, and for a few days he was kept on the 
double-inclined plane. The straight splint was then used, and the dress- 
ings kept up for six weeks ; at the end of that time they were taken off, 
and the limb examined; there was no union. The limb was continued 
in the straight splints for three weeks longer, and again examined; there 
was still no union. The patient was again replaced in the straight splint 
for two weeks longer, but no union occurred. At the end of three 
months from his admission he was discharged; he was in good health, 
but so lame that he was obliged to use two crutches in w T alking. After 
his discharge the patient became very intemperate; and in the course of 
a few weeks he applied for admission to Bellevue Hospital. He was 
much debilitated, and had an exhausting diarrhoea. Shortly after his 
admission an immense abscess formed over the joint, which discharged 
profusely. The man died shortly after from exhaustion, and the speci- 
men came into Dr. Van Buren's hands, the patient having been in his 
service. Dr. Van Buren was aware of the patient's previous history, 
the treatment, etc., at the New York Hospital, and a careful examina- 
tion was made. 

"The capsular ligament was destroyed entirely by the suppurative 
process; there was a formation of callus upon the trochanter major; the 
ligamentum teres was entirely absorbed; the head of the bone was 
spongy, as if worm-eaten: the direction of the fracture was oblique, 
commencing just at the articulating surface of the head, and ending just 
within the capsule; the upper end of the shaft of the bone showed this 
-nine appearance that was marked in the head. These points are beau- 
tifully shown in the specimen at the present time. The opinion of 
Charles E. Isaacs, M.D., the able Demonstrator of Anatomy of the 



NECK, WITHOUT THE CAPSULE. 445 

University Medical College, is, that this fracture was entirely within the 
capsule. " l 

Such equal results from opposite plans, and unequal results from simi- 
lar plans of treatment, are not calculated to increase our faith in the 
testimony which most of the foregoing examples are supposed to furnish 
of the possibility of bony union. On the contrary, they cannot fail to 
suggest a doubt as to whether some of them, at least, were not inaccu- 
rately diagnosticated. 

But admitting that they were not, the testimony which they furnish in 
relation to treatment is too inconclusive to be made available for instruc- 
tion, and we are still at liberty to adopt that which seems most rational, 
without reference to the experience of others. 

The reasons why I would prefer my own plan have already been stated 
in part, to which I will now add, that if an error should occur in the 
diagnosis — if it should prove finally to have been a fracture without the 
capsule — then this treatment would be correct, and no injury would come 
to the patient from the error in diagnosis; but if we adopt Sir Astley 
Cooper's suggestion, namely, to get the patient upon crutches as soon as 
possible, perhaps as early as fourteen days, an error in diagnosis might 
be followed by the most disastrous consequences. 

In gunshot intracapsular fractures, if suppuration ensues, the head of 
the bone and other fragments ought to be removed ; and there may occur 
in which the fragments should be removed immediately, as has been 
done occasionally with satisfactory results. So, also, if after a simple 
intracapsular fracture, suppuration within the joint were to ensue, resec- 
tion would be the proper resort ; but I cannot agree with Dr. How T e in 
his report of a case to the New York Academy of Medicine, that, in all 
of intracapsular fractures of the neck of the femur, occurring in 
persons who were not very decrepit or exhausted, and where crepitus 
was well marked, at the end of three months of careful treatment, and 
the patient confined to bed. the operation of excision should be performed 
without delay. 2 The probabilities seem to be that in most or all of these 
the patient is likely to have as useful a limb without excision as 
with, and if so, the hazards of the operation, however trivial, must de- 
cide the question against its performance. Tn the case operated on by 
Dr. Howe, the result is by no means encouraging, and it is apparent 
that the limb was not judiciously managed before the operation. It was 
kept too long in splint-. 

(b) Neck of the Femur, without the Capsule. (Uztracajwular.) 

Causes. — Like fractures within the capsule, these also occur most fre- 
quently in advanced life. They art- not, however, as often met with in 
extreme old age a- arc fractures within the capsule; and tiny arc much 
more often met with in persons of middle age, and in younger persons, 
than are intracapsular fractures. Of fractures recognized as extracap- 
sular, in \)v. Hyde's tables, ten were under fifty years, and -even ;it or 

1 Johnson, op. cit., pp. 18- 16. 

2 J. W. Howe. M.I;., Boepital Gki - 20, 1879, p. 660; alt i the Debate, p. 

66-5, in which other similar operations are cited. 



44t> FRACTURES OF THE FEMUR. 

over fifty. The three youngest were respectively thirty, twenty-five, 
and twenty years of age.. Of the 42 recorded by me as extracapsular 
fractures, I have made no careful tabulation of the ages, but it is certain 
that in general they belong to a younger class of persons than the cases 
recorded as intracapsular. 

As to the immediate causes, I have already mentioned in the pre- 
ceding section that fractures without the capsule seem to be the result 
generally of falls or of blows received directly upon the trochanter ; 
occasionally, also, they are produced by falls upon the feet or upon the 
knees. 

Pathology. — These fractures may occur at any point external to the 
capsule, but generally the line of fracture is at the base, corresponding 
very nearly with the anterior and posterior intertrochanteric crests. 
Almost invariably the acetabular penetrates the trochanteric fragment 
in such a manner as to split the latter into two or more pieces. The 
direction of the lesions in the outer fragments preserves also a remark- 
able uniformity ; the trochanter major being usually divided from near 
the centre of its summit, obliquely downwards and forwards tow T ard its 
base, and the line of fracture terminating a little short of the trochanter 
minor, or penetrating beneath its base ; while one or two lines of fracture 
usually traverse the trochanter major horizontally. 

In an examination of more than thirty specimens, I have noticed but 
two or three exceptions to the general rules above stated. 

In Dr. Miitter's collection, specimen marked B 115 is not accompanied 
with either impaction or splitting of the trochanteric fragment ; but the 
neck, having been broken close to the intertrochanteric lines, has, appar- 
ently, slid down upon the shaft about one inch, at which point it is 
firmly united by bone. 

Dr. Neill has also a specimen of fracture at the same point, but with- 
out union of any kind, in which no traces remain of a fracture of the 
trochanters. The acetabular fragment has moved up and down upon the 
trochanteric until it has w T orn for itself a shallow socket three inches and 
a half long ; the approximate surfaces being smooth and polished like 
ivory. 

The trochanter major is usually turned backwards, the shaft of the 
femur being rotated in this direction, the same as is usually observed in 
other fractures of the neck of the femur. I have seen one exception to 
this general rule in a specimen belonging to Dr. Mutter (No. 29) ; the 
trochanter in this instance is turned forwards, so that the neck is shorter 
in front than behind. 

The upper fragments of the trochanter major, whenever the lines of 
fracture are transverse, are generally inclined inwards toward the neck, 
as if displaced in this direction by the force of the blow, or perhaps by 
the resistance offered by certain muscles and ligamentous bands which 
find an insertion upon its summit. 

The neck is found, in most cases, standing inwards at nearly a right 
angle with the shaft, the head being much more depressed than the outer 
extremity of the neck ; in consequence of which the lower margin of its 
broken extremity is driven much deeper into the trochanteric fragment 
than is the upper margin. 



XECK. WITHOUT THE CAPSULE. 



447 



Malgaigne believes that impaction, with consequent fracture of the 
trochanters, is never absent in true extracapsular fractures, unless it be 
in that very unusual variety in which the trochanter forms a part of the 
inner fragment (fractures through the trochanter major and base of the 
neck). Robert Smith entertains the same opinion, although Malgaigne 
does not seem to have so understood him. I cannot agree, however, with 
either of these gentlemen that the rule is so invariable, since I am con- 
fident that no such splitting has occurred in either of the two specimens 
to which I have referred as belonging respectively to Drs. Mutter and 
Neill. It is true these are both old fractures, and to some extent the 
signs of fracture may have become obliterated, but in Miitter's specimen 
an abundant callus indicates plainly enough where the shaft separated 
from the neck, while the trochanter major is smooth as in its normal con- 
dition, nor does its summit incline either way from its normal position. 
XeilFs specimen, though less satisfactory, does not fail to convince me 
that neither impaction nor splitting of the trochanters ever occurred. 

It is certain, however, that impaction and comminution of the outer 
fragment are very constant, and that, whether the fracture is produced 
by a tall upon the feet or upon the trochanter major. But the inrpac- 
tion does not necessarily continue : sometimes, indeed, it does, and the 
position of the limb, whatever it may be at the moment, remains un- 
alterablv fixed : either verv little or considerably shortened, according 



Fig. 142. 



Fig. 143. 



Fig. 144. 




Impacted extracapsular fracture?. (R. Smith, and Erichsen.) 



to the degree of impaction ; rotated outwards or inwards, or in neither 
direction, perhaps, according to the direction of the force and the amount 
of comminution. In other cases, owing t<» the extreme comminution, 
and to the wide separation of the trochanteric fragments, or to the con- 
traction of the muscles inserted into the top of the femur, or to the 
weight of the body in attempts to walk, or to injudicious handling on 
the part of the surgeon, such a- forcible rotation, by which the Deck is 
made to act as a lever, and actually to pry the fragments apart, or to 



448 FRACTURES OF THE FEMUR. 

violent extension, by which the impaction is overcome — owing to some 
one or several of these causes it often happens that the fragments sepa- 
rate, and the leg becomes immediately more shortened, movable, and 
more inclined to rotate outwards. 

Symptoms, — The symptoms which indicate a fracture of the neck of 
the femur without the capsule, are pain, mobility, crepitus, shortening, 
and eversion of the limb. The trochanter major is not as prominent 
as upon the opposite side; and especially where the fragments are not 
impacted, but are completely separated, it rotates upon a shorter axis. 
There are also several other signs to which I shall refer when consider- 
ing the differential diagnosis. 

Before considering more in detail the value of these several signs, I 
wish to call attention to a fact which has been often observed by myself 
and others, namely, that the patient is able, sometimes, immediately 
after this accident, to take a few steps; yet never, perhaps, without 
considerable pain. The same may happen in an intracapsular impacted 
fracture, but it happens much more often in the extracapsular impacted 
fracture ; but the following case is the most remarkable, in this point of 
view, of any which has come under my notice: A laboring man, about 
50 years of age, presented himself at my clinic at Bellevue Hospital, 
some time during the fall of 1874, who stated that two years before he 
had fallen a distance of nine feet, striking upon his side ; that after a 
little he arose, and with the aid of a stick, walked a mile or more to 
his home. Walking caused great pain in his hip, and he was much 
exhausted when he reached home, and went to bed; but, having no 
suspicion that his limb was broken, he did not call a surgeon. Within 
a fortnight from this time he began to walk about, and a week later he 
began to perform ordinary labor, yet not without pain. 

When this man came before the class I found the limb shortened 
three-quarters of an inch, the toes everted, the trochanter major de- 
pressed — that is, flattened — irregular in form, and much increased in 
breadth. He is a man of intelligence, and is certain that these changes 
of form, etc., were observed by him very soon after his recovery. It 
seems proper, therefore, to assume that this was not an example of 
gradual change of form and position due to a chronic ostitis, but that it 
was an extracapsular fracture. 1 

The pain and tenderness, accompanied sometimes with swelling and 
discoloration, are situated most often in front of the neck of the bone. 

Articular mobility exists in a majority of cases; that is, the limb can 
be moved pretty easily in any direction by the surgeon, but not without 
producing pain or provoking muscular spasms. In most cases the 
patient himself is unable to move the limb by his own volition, or he can 
only move it slightly. 

Crepitus is present whenever there exists a moderate but not com- 
plete impaction. It is also present generally when, the trochanteric frag- 
ment, having been extensively comminuted and loosened, the impaction 
becomes excessive ; and it is only absent when the impaction is such that 
the fragments are completely and firmly locked into each other. 

1 Canton on Interstitial Apsorption of the Neck of the Femur from Bruise, etc. 
London Med. Gazette, Aug. 11, 1848. 



NECK, WITHOUT THE CAPSULE. 



449 



Fig. 145 



A shortening is inevitable, at least in all cases accompanied with 
either temporary or permanent impaction, and we have seen that one 
of these conditions seldom fails. According to Sir Astley Cooper, the 
shortening varies from half an inch to three-quarters of an inch; but 
Robert Smith has established the following distinction: When the frac- 
ture is extracapsular and impacted, that is, when it remains impacted, 
the shortening is only moderate, varying from one-quarter of an inch to 
one inch and a half: in fourteen cases measured by him the average was 
a fraction over three-quarters of an inch; but when it does not remain 
impacted it ranges from one inch to two inches and a half; indeed, Mr. 
Smith mentions one example in which the shortening reached four inches, 
and forty-two cases gave an average shortening of something more than 
one inch and a quarter. Mr. Smith's experience as to the amount of 
shortening in these cases agrees very nearly with my own. 

Eversion of the toes is very constant; but in a few instances upon 
record the toes have been found turned in, or even directed for- 
wards. During the winters of 1864 and 1865, 
I found a case of this kind in my wards at Bellevue 
Hospital. In the specimen referred to as being 
found in Dr. Mutter's collection, with an inward or 
forward rotation of the trochanter major, the same 
relative position of the whole limb must have ex- 
isted ; and in my remarks on fractures of the neck 
within the capsule, I have referred to several ex- 
amples, some of which were probably extracapsular. 

The trochanter major usually seems depressed or 
driven in ; and when the two main fragments are 
completely separated, if the limb is rotated, the 
trochanter will be found to turn almost upon its 
own axis, or upon a very short radius. 

In enumerating the signs of a recent extracap- 
sular fracture, it will be seen that I have, with only 
slight variations, repeated the signs of a fracture 
within the capsule. It will become necessary, there- 
fore, to indicate, as fir as possible, a differential 
diagnosis. And without pretending that all of the 
differential signs which I shall enumerate are 
thoroughly established, or that in every case, even 
after a careful grouping of all the symptoms, a 
satisfactory diagnosis can be made out, I shall 
state briefly my own conclusions, or rather what seem to me to be the 
probable fa 

01 A FliA' HUH WITHES THE SlGNS OF A FRACTURE WITHOUT THE 

CAPSULE. CAPSULE. 

Produced often by slight violence. Produced usually by greater violence. 

A. fall upon the foot or knee, or a trip A fall upon the trochanter major in 
upon the carpet, etc. Possibly a fall upon nearly all cases, 
the trochanter; especially when an old 
person is the subject of the injury. 

rally over fifty years of i Often under fifty years of ago. 

More frequent in fern;. Kelative frequency in males or females 

not established. 
29 




Fracture of the neck of 
the femur. (Fergusson.) 



450 



FRACTURES OF THE FEMUR. 



Signs oi a fracture within the 

CAPSULE {continued). 
Pain, tenderness, and swelling less and 
deeper. 



Ecchymosis not often seen. 

(The two following measurements to be 
made from the lower margin of the an- 
terior superior spinous process of the ilium 
to the lower extremity of the malleolus 
externus or internus.) 

Shortening at first less than in extra- 
capsular fractures, often not any. 

Shortening after a few days or weeks 
greater than in extracapsular fractures. 
Sometimes this takes place suddenly, as 
when the limb is moved, or the patient 
steps upon it. 



Measuring from the top of the tro- 
chanter to the condyles or to the malleoli, 
the limb is not shortened. 

If there is no impaction, the trochanter 
major moves upon a relatively longer 
radius than in cases of extracapsular frac- 
tures, the pivot being nearer the acetabu- 
lum. 

If the patient recovers the use of the 
limb, not restored under many months, 
or years. 

ISTo enlargement or apparent expansion 
of the trochanter major, after recovery, 
from deposit of bony callus. 



Progressive wasting of the limb for 
many months after recovery. 

Eventually excessive halting, accom- 
panied with a peculiar motion of the 
pelvis, such as is exhibited in persons who 
walk with an artificial limb. 



Signs or a fracture without the 
capsule (continued). 

Pain, swelling, and tenderness greater 
and more superficial. It is especially 
painful to press upon and around the 
trochanter major. 

Superficial and extensive ecchymosis 
quite frequent. 



Shortening at first greater, almost al- 
ways some. 

Shortening after a few days or weeks 
less than in intracapsular fractures, pro- 
vided proper extension has been main- 
tained. That is, the amount of shortening- 
changes but little, if at all, if the impac- 
tion continues. If it does not continue, it 
shortens more. 

Measuring from the top of the tro- 
chanter to the condyles or to the malleoli, 
the limb may be found a little shortened. 

If there is no impaction, the trochanter 
major moves upon a relatively shorter 
radius, the pivot being more remote from 
the acetabulum. 

The patient usually recovers the use of 
the limb sooner. In many cases, however, 
very slowly, and walking is for a long 
time difficult and painful. 

Enlargement or irregular expansion of 
trochanter, which may be felt sometimes 
distinctly through the skin and muscles, 
and which is especially manifest after the 
lapse of some months. 

The limb preserving more nearly its 
natural strength and size. 

Comparatively slight halt, motions of 
hip more natural. 



Prognosis. 1 — In attempting to establish the differential diagnosis, we 
have necessarily been led to consider most of the essential points of 
prognosis. Very little, therefore, remains to be said upon this subject. 

Union occurs as rapidly in this fracture as in fractures of the shaft ; 
and perhaps in general more promptly, owing to the existence of im- 
paction. 

But whether it occurs promptly or slowly, or, indeed, if it does not 
occur at all, a remarkable deposit of ossific matter almost invariably 
takes place along the intertrochanteric lines, where the bone has sepa- 
rated from the shaft, and also, not unfrequently, along the lines of the 
other fractures of the trochanter. 

This deposit is no less remarkable for its abundance than for its 
irregularity, long spines of bone often rising up toward the pelvis and 



1 See observations of Dr. Frederick E. Hyde in preceding section. 



NECK, WITHOUT THE CAPSULE. 



451 



forming a kind of knobby or spiculated crown, within which the acetabular 
fragment reposes. In a few instances these osteophytes have reached 
even to the bones of the pelvis, and formed powerful abutments, which 
seemed to prevent any farther displacement of the limb in this direction, 
and by some writers* they have been supposed thus to fulfil a positive 



Fig. 146. 



Fig. 147 




Extracapsular fracture. (Erichsen.) 




Extracapsular fracture, 



mith.) 



design. A sufficient explanation of their existence, however, I think, 
can be found in the fact that they proceed entirely from the trochanteric 
fragments, whose extensive comminution and great vascularity would 
naturally lead to such results. The same, but in a less degree, has 
already been noticed as occurring in impacted fractures at the anatomi- 
cal neck of the humerus, where certainly such bony abutments could not 
serve any useful purpose. 

Probably in all, certainly in nearly all cases, the limb will be found, 
after the union is consummated, more or less shortened, generally between 
half an inch and an inch. If exceptions ever occur, it must be in those 
examples in which there is no impaction, and it is certain that such 
examples are very rare. Such is the united testimony of all surgeons 
whose opinions have ever been respected as authority; and the same is 
feme of intracapsular fractures. What ignorance of the elementary facts 
of surgical science, or insincerity, then, do those men exhibit who affirm 
that they are able to treat all fractures of the femur without shortening ! 

Eversiou of the foot i- not so constant as shortening, but it will be 

found t<> exist in some degree in ;i large majority of cases, even when the 

has been managed in the most skilful manner: yet in this regard 

something will depend upon the position in which the limb is maintained 

during the treatment. 

Treatment. — The same principles of treatment are applicable here as 
in fracture- of the neck within the capsule; by which I mean to 
that, as in all of those examples of fracture within the capsule where 



452 



FRACTURES OF THE FEMUR. 



the relation of the fragments is such as to warrant a hope that a bony 
union may be consummated, namely, where the fragments are not dis- 
placed or are impacted, the straight position, with only moderate ex- 
tension, constitutes the most rational mode of treatment ; so also in this 
fracture, whenever the fragments are impacted and remain impacted, 
the straight position, with moderate extension, employed only as a 
means of retention, but not so as to overcome impaction, is the most 
suitable. It is only by employing this plan of treatment, which no one 
has yet shown to be inapplicable to either of these two varieties of acci- 
dents — I do not speak of the opinions which men may have entertained, 
but of the practical testimony — it is only, I say, by employing this uni- 
form plan of treatment in both cases, that those serious misfortunes to 
the patient can be avoided which would necessarily continue to occur if 
Sir Astley Cooper's advice were followed, namely, to allow the patient 
in the one case to dispense with apparatus wholly, and to get upon his 
crutches as soon as the condition of his limb and of his body will per- 
mit, when it is certain that in the other case some retentive apparatus 
is generally necessary. This conclusion is based upon the admitted 
difficulty of diagnosis. If, as is well understood, the diagnosis between 
these two varieties of fracture is often impossible during the life of the 
patient, then how shall we know in any given case which of the two 
plans to adopt ? If we act upon the supposition that it is within the 
capsule, adopting Sir Astley Cooper's method, and it proves to have 
been a fracture without the capsule, we 
Fig. 148. may do irreparable injury to our patient. 

It is precisely here that this distinguished 
surgeon committed his great error ; not in 
denying that certain specimens were frac- 
tures of the neck of the femur within the 
capsule united by bone, nor in constantly 
urging upon his contemporaries the im- 
probability of such an event ; but in that, 
while he admitted its possibility, he chose 
to recommend a plan of treatment which 
was unlikely to insure such a union, and 
which, in the uncertainty, if not impossi- 
bility of diagnosis, was liable, upon his 
supposed authority, to be adopted in many 
Extracapsular fracture. cases of extracapsular fractures. 

Again, if the fracture be extracapsular 
and not impacted, or the impaction has been, for any cause, overcome ; 
or, if the fracture be intracapsular and not impacted ; or if the capsule is 
lacerated and the fragments are in consequence displaced ; then again no 
injury need result from the treatment, if we adopt the straight position 
with moderate extension, such as may be obtained from the use of my 
apparatus. That it is or is not impacted we may know generally by 
the amount of displacement, although we may not easily decide whether 
the fracture is within or without the capsule. Now, the amount of 
shortening will determine properly enough the amount of extension to 
be employed. In either case, however, we shall not employ as much 




NECK OF THE FEMUR. 



453 



extension as in fractures of the shaft : and while if it be an intracap- 
sular fracture we may only gain a shorter and firmer ligamentous union, 
if it proves to be extracapsular we shall insure a better and more speedy 
bony union. 

If any surgeon, acting upon the suggestions here made, shall confine 
a feeble or an aged person in the horizontal posture, with or without a 
straight splint, until the powers of nature have become exhausted, and 

Fig. 149. 




Miller's splint for extracapsular fracture. (From Miller.) 



death ensues, as our readers have already been admonished may happen, 
we are not to be held responsible for his want of judgment or of skill. 
We have advised this plan of treatment only for so long a period as the 
condition of the patient renders it entirely safe, or as it can prove useful. 
No doubt, then, in a large number of cases, it will have to be abandoned 
very early, and in not an inconsiderable proportion all constraint will be 
plainly inadmissible from the beginning ; and it is for such examples 
that the treatment recommended by Sir Astley Cooper for all intracap- 
sular fractures ought to be reserved. 1 

(c) Fractures of the Neck, partly within and 'partly without the Capsule. 

It is scarcely necessary to say that the line of fracture through the 
neck of the femur may be such, that it shall be in part within and in part 
without the capsule; and such fractures will be even more difficult to 
diagnosticate than either of those forms of which we have just spoken. 
The symptoms will be mainly, however, those which characterize frac- 
ture- within the capsule, while the treatment ought to be such as we 
would adopt in those fractures which are wholly without the capsule. 
The chances for bony union are increased in proportion as the line of 
separation extends outside of the capsule, and we ought to be diligent 
in our efforts, if we have made ourselves certain that the fracture is 
partly extracapsular, to secure a good bony union; a result which ex- 
perience has shown may be reasonably anticipated. 

The necessity for some extension, and of firm retentive apparatus in 
this form of fracture, furnishes another argument in favor of the employ- 
ment of the same means in fractures wholly within the capsule. We 

1 Fracture at the Nock of the Femur. Clinical Lecture at the Bellevue Hospital, 
bv the Author. Priority in Employment of Extension, etc. The Medical Record, 

March 9. ]-' 




454 FRACTURES OF THE FEMUR. 

shall tli us avoid the mischief which might arise from mistaking a fracture 
of the character of which we are now speaking, for a fracture wholly 
within the capsule. 

§ 2. Fracture of the Trochanter Major. 

Under the title of "Fracture through the Trochanter Major," Sir 
Astley Cooper 1 writes as follows: "Fractures sometimes happen through 
the trochanter major obliquely, and the cervix ossis 
Fig. 150. fern oris does not participate in the injury;" and 

among the illustrations contained in the same vol- 
ume, Figure 2, Plate xii., "exhibits," says Sir Astley, 
ww the seat of fracture of the trochanter major often 
mistaken for fractured cervix femoris ; this fracture 
unites by bone." 

This illustration is supposed to refer to the frac- 
ture spoken of by him as one which " sometimes 
happens " through the trochanter obliquely without 
involving the neck. The line of this supposed 
fracture, as shown in the illustration, is from near 
the top of the trochanter major downwards and 
Sir Astley Cooper's im- inwards, and terminating on the shaft just below 
aginary fracture. From the trochanter minor. It does not, therefore, in- 

Treatiseon Dislocations yolye the Reck but ft geverg ^ thieh-bano COm- 
and Fractures of the -, -. ° 

Joints, 2d, London ed., P le ^ el J\ 

1823, pi. xii., Fig. 2. Sir Astley describes briefly in the text the first 

case of "this kind " he " ever saw." " It was in St. 
Thomas's Hospital, about the year 1786." Mr. Cline thought it to be 
a fracture of the neck, but the patient having subsequently died, " the 
fracture was found through the trochanter major." 

It does not appear whether Sir Astley witnessed the dissection, nor is 
there any statement to the effect that the line of fracture was the same 
as that indicated in the woodcut. 

His second case, which he saw in consultation with Mr. Harris, was 
not verified by an autopsy ; and upon a careful reading of the report as 
given by Mr. Harris, lam unable to find a particle of evidence that it 
was such a fracture as Sir Astley supposed it to be. Indeed all that 
Mr. Harris says upon this point in his report is, that Sir Astley " agreed 
with Mr. Brodie and ourselves in declaring the fracture to be placed in 
the trochanter major, where it unites with the cervix femoris." In all 
probability, therefore, it was an extracapsular impacted fracture, or, 
perhaps, it was a simple fracture across the base of the trochanter. 

Sir Astley believed that he had seen three other similar cases in the 
course of his practice, none of which, however, were established by dis- 
section. 

The example reported by Stanley, 2 of a woman 60 years old, who died 
three years after having fallen and injured her right hip, was certainly 

1 Sir Astley Cooper, on Dislocations and Fractures of the Joints. London, 2d ed., 
1823, p. 158. 

2 Stanley, Med. -Chir. Trans., vol. xiii. p. 504. 



FRACTURE OF THE TROCHANTER MAJOR. 455 

not an example of the fracture described by Sir Astley ; but in all prob- 
ability it was an extracapsular fracture, with sufficient comminution to 
have separated the trochanter major from the shaft of the femur. Mr. 
Bransby Cooper's case 1 is equally unsatisfactory. The cases described 
by Waechter 2 and by Clarke 3 have been classified as trochanteric frac- 
tures, but they would be more properly called extracapsular impacted 
and comminuted fractures of the neck and trochanter. The case re- 
ported by Waechter may be given as an illustrative example of some of 
the accidents of this latter class. 

A man 71 years old, fell upon his left hip. A week later he was 
admitted to the hospital. There was no sign of contusion and no crepi- 
tation. Outward rotation alone caused pain. Subsequently the limb 
became Hexed, rotated inwards and adducted. Four weeks after the 
accident he died of pneumonia. " The round ligament was found to be 
hyperaemic, but there was no effusion within the joint. The upper and 
inner portion of the trochanter was separated by a line of fracture which 
lay entirely outside the joint, beginning close by the upper edge of the 
insertion of the capsule, running downwards and outwards, and then up 
across the top of the trochanter. The fragment, which was split into 
two pieces that were slightly movable on each other, was slightly 
displaced backwards and inwards, and the periosteum was torn in front, 
but not on the outer side. The tendons of the pyriformis, obturator 
internus and gemelli. and the anterior fibres of the gluteus medius, and 
upper fibres of the glutaeus minimus remained attached to the fragment. 
There was no sign of repair : no extravasation of blood. A fissure, three 
centimetres long in the shaft, made the remaining half of the trochanter 
slightly movable." 

In short, I am compelled to say that the fracture described by Sir 
Astley unaccompanied with comminution of the trochanter major, has 
probably never been met with. The illustration which he furnished of 
this accident was drawn, not from any such specimen seen by himself, 
but from his own ideas as to what conditions of the fracture would best 
explain the clinical phenomena presented. Surgeons of Sir Astiey's 
day had not become bo well acquainted with the variety of conditions in 
which an extracapsular impacted fracture may be found. In some cases 
the penetration being almost imperceptible, while in others the pentra- 
tion is Buch as to separate the trochanter into several fragments, some of 
which may be completely detached and displaced. 

Sir Astley Cooper's error in diagnosis, as Malgaigne docs not hesitate 
to call it. ha- embarrassed and misled many who have attempted to study 
this subject; and which embarrassment can only be relieved by a com- 
plete rejection of all that Sir Astley lias written upon it. 

And now, having disposed of the fracture imagined by Sir Astley, 
and having the consideration of a true fracture of the trochan- 

ter major, it becomes necessary to Bay that I have not found anywhere re- 
ported an example of this fracture demonstrated by dissection, other than 
epiphyseal separations and the fractures of the trochanter caused by im- 

1 B I Dislocations, etc., p. 192. 

2 AVaecht' : 1 1 U Z - fur Chir., vol. viii. 1877, p. 104 (Stim 

3 Clarke. Amer Joum vol ir. p. 181, from Trans. Med. Phys. 

- , Cal - - - " 



456 



FRACTURES OF THE FEMUR. 



paction of the neck just referred to. Agnew gives an illustration of a 
specimen contained in his cabinet, and which he describes as a "fracture " 
of the epiphysis, but he does not indicate whether he regards it as a true 
fracture or an epiphyseal disjunction. 1 I know of no other supposed 
cabinet specimen, and of no clinical example confirmed by dissection. 

Reports of clinical examples not confirmed by dissection, are almost 
equally rare. Agnew says that, in 1181 fractures of the thigh treated 
in the Pennsylvania Hospital, this injury was recognized only four 
times ; but he furnishes no description of either of the cases. 

I have also myself reported one example of this fracture as having 
come under my own observation. 2 The patient, James Redwick, a 
travelling showman, set. 23, fell, August, 1848, from a high wagon, 
striking upon his left hip. When he got upon his feet, he found 
himself unable to walk, and was carried to his room. Dr. Wilcox, 
of Buffalo, was called to see him and applied a long straight splint. 
Fourteen days after the accident I saw the patient with Dr. Wilcox. 
The thigh was not appreciably shortened, nor was there any eversion 
nor inversion; but the epiphysis of the trochanter major was carried 
upwards toward the crest of the ilium half an inch, and slightly sent in. 
No crepitus could be detected. The splint was continued five weeks ; 
and about a month after, I found the fragment in the same place, but 
he was able to walk with only a slight halt. I cannot say that the case 
admits of no doubt as to the true character of the accident, although at 
the time I entertained no doubt. I think now T it may possibly have been 
an extracapsular impacted fracture. 

Symptoms and Treatment. — Considering the limited amount of infor- 
mation we possess upon the subject of true fractures of this process, I 
shall refrain from offering any opinion as to the symptoms or treatment. 
It will be more prudent, it seems to me, to leave these matters for the 
present to the more intelligent decision of the surgeon who is in at- 
tendance. 



§ 3. Separation of the Epiphysis of the Trochanter Major. 



Fig. 151. 




Mr. Aston Key's ease. 
Prep. 1195, Guy's -Mu- 
seum. (From Bryant.) 



An example of this accident was reported by Mr. 
Key to Sir Astley Cooper. 3 The subject was a 
girl, aged about sixteen years, who fell, March 15, 
1822, upon the sidewalk, and struck her trochanter 
violently against the curbstone. She arose, and, 
without much pain or difficulty, walked home. On 
the 20th she was received into Guy's Hospital, and 
the limb was examined by Mr. Key. The right 
leg, which was the one injured, was considerably 
everted, and appeared to be about half an inch 
longer than the sound limb. It could be moved in 
all directions, but abduction gave her considerable 
pain. She had perfect command over all the muscles, 



1 Agnew, Treat, on Surgery, vol. i. p. 945. 
- Trans. Amer. Med. Assoc, vol. x. p. 254. 
3 Sir Astley Cooper, on Dislocations and Fractures, etc., 1851, Amer. ed , p. 192. 



SEPARATION OF EPIPHYSIS OF TROCHANTER. 457 

except the rotators inwards. No crepitus could be detected. Four days 
after admission she died, having succumbed to the irritative fever which 
followed the injury. 

The autopsy disclosed a fracture through the base of the trochanter 
major, but without laceration of the tendinous expansions which cover 
the outside of this process, so that no displacement of the epiphysis had 
occurred, nor could it be moved, except to a small extent upwards and 
downwards. A considerable collection of pus was found, also, below and 
in front of the trochanter. 

The absence of displacement in the fragment, with its peculiar and 
limited motion, sufficiently explained why the fracture could not be 
detected during life. 

A case was reported by McCarthy to the Pathological Society, and is 
printed in the Transactions as "a traumatic separation of the trochan- 
teric epiphysis." similar to Aston Key's, quoted above. The patient 
was a girl eight years old, who, when brought to the hospital, was con- 
sidered too ill to be examined, and died a few hours afterwards. 

The history was. that she had never had any illness previous to a fall 
on the left side a week before, while playing. A day or two later a lump 
was noticed on the left hip, and the child was kept in bed in conse- 
cpience. A few days later her breathing became so difficult that she 
was brought to the hospital, walking the distance, half a mile, and not 
complaining of pain. The autopsy showed " pyaemic pericarditis, pleu- 
risy, and pneumonia." a large extra-peritoneal abscess in the pelvis, con- 
necting alone: the tendon of the pyriformis with another around the neck 
of the femur. The trochanteric epiphysis was completely detached from 
the shaft, but held in position by tendinous attachments and reflections 
of the capsule. 1 

A very interesting case has been reported by Prof. T. J. Roddick, of 
Montreal, Canada. 2 A lad. set. 16, became lame in consequence, as 
Dr. Roddick thinks probable, of leaping a fence in pursuit of a ball. 
Subsequently an ahscess formed over the trochanter, which was opened. 
A few weeks later he died, apparently as a consequence of pysemic in- 
fection. It was then found that the trochanter was lying in ;i ma-- of* 
pus, entirely separated from the shaft, and with no other lesion. 

Mr. Poland 3 reports a ease, also, which occurred in a boy twelve years 
old (no doubt, therefore, it was an epiphyseal separation), at Guy's Hos- 
pital, and which was seen by Mr. Bryant : but tin- was not confirmed 
by an autopsy. It was caused by ;i direct blow, and " was characterized 
by thickening and projection of the trochanter." 

— Tic cases reported by Mr. Key. McCarthy, and Rod- 
dick would seem to show that in epiphyseal separation of this process 
there is a peculiar tendency to the formation of pus, and of general 
pysemic infection, and which may perhaps find its explanation in the 
Hilarity of the bony structure at this point, and in the fact that 
the lesion of this spongy tissue especially exposes the patient to the 
absorption of the septic materials. 

i arthy, Trans. P Ion, vol. 25, 1874, p. 200 

- I: : li( ... Canada M _. Jouro., Nov. 1870, p. 207. 

3 Poland, Bryant"? Surgery, 1st London ed., )>. 960. 



458 FRACTURES OF THE FEMUR. 

The author must repeat what he has said in the preceding section, 
that he is not prepared to make any suggestions as to either the symp- 
toms, prognosis, or treatment, unless it be to say that, in view of the 
tendency to suppurative action, the limb should be kept at rest. 

§ 4. Fractures of the Shaft of the Femur. 

Etiology. — Unless the fracture has taken place just above the con- 
dyles, or immediately below the trochanter minor, in a very large pro- 
portion of cases it has been produced by a direct blow, such as the 
passage of a loaded vehicle* across the thigh, or the fall of a piece of 
timber directly upon it. 

Pathology. — It has already been remarked that this bone is most 
frequently broken in its middle third, and usually at a point somewhat 
above the middle of the shaft. I have made the same observation in an 
examination of specimens belonging to Dr. Mutter. In his cabinet, of 
twenty-four fractures of the shaft, three belonged to the upper third, 
two to the loAver, and nineteen to the middle third. 

In the adult these fractures are, with only an exceedingly rare excep- 
tion, oblique; and the obliquity is generally greater than in the case of 
other bones. This fact, which is very difficult to determine, in most 
cases, upon the living subject, I have established by a considerable 
number of observations made upon cabinet specimens. A transverse 
fracture is found only twice in Dr. Mussey's collection, containing 
thirty examples of fracture of the shaft; and in Dr. Mutter's collection, 
specimen B 71 is an adult femur, broken nearly transversely through its 
middle third ; and it is united with a shortening of about one inch. 
Indeed, it is more common to find a transverse fracture in the middle 
third than at any other point of the shaft of the bone; but in the upper 
third the obliquity is extreme and almost constant. 

At whatever point of the shaft the bone is broken, the degree of ob- 
liquity is generally such that the fragments cannot support each other 
when placed in apposition; unless indeed. the fracture is near the con- 
dyles, where the greater breadth of the bone creates an additional sup- 
port ; but even here the cabinet specimens still present a striking 
obliquity, with more or less overlapping. I believe that in each of the 
three specimens of fracture at this point found in the collection belong- 
ing to the Albany Medical College, the obliquity is such that the frag- 
ments were not supported, and an overlapping has taken place. In 
specimen 711' the fracture extends into the joint; and although it is 
united by bone, a shortening of about one inch has occurred. 

In two cases to which I shall hereafter refer, the upper fragment was 
projected through the quadriceps tendon, and became imprisoned under 
the skin. 

In the case of* children, and especially of infants, the bone is not un- 
frequently broken transversely or nearly transversely, or it is serrated 
or denticulated, so that complete lateral displacement is much less fre- 
quent. 

The same remark is probably true of a few fractures occurring in 
extreme old age ; but as the shaft of the femur is not often broken in 



FRACTURES OF THE SHAFT OF THE FEMUR. 459 

very old persons, owing to the readiness with which the neck yields to 
violence. I have not had an opportunity to verify this opinion. 

The direction of the obliquity varies exceedingly, especially in the 
middle and upper thirds : in the middle third, however, it is generally 
downwards and inwards ; but in the lower third its direction is, with 
only rare exceptions, downwards and forwards, and the superior frag- 
ment is found lying in front of the inferior. 

The direction of the displacement, however, in fractures of the shaft 
of the femur, does not always depend upon the direction of the line of 
fracture. In fractures of the upper third, whatever may be the direc- 
tion of the line of fracture, the lower end of the upper fragment inclines 
forwards and outwards, and the upper end of the loAver fragment in- 
wards : unless, indeed, this inclination is controlled by actual entangle- 
ment of the broken ends with each other. 

In the middle third the fragments also generally take the same rela- 
tive position, whatever may be the direction of the fracture ; but when 
the fracture takes place at or near the condyles, where the diameter of 
the bone is much greater, the direction of the obliquity determines pretty 
uniformly the direction of the displacement. 

Symptoms. — The symptoms which characterize a fracture of the shaft 
of the femur are those which are common to all fractures, namely, mo- 
bility, crepitus, displacement of the fragments, pain, and swelling, to 
which are added generally a shortening of the limb, with eversion of the 
foot and leg. 

Owing to the great amount of muscle covering the thigh, or to the 
swelling which immediately follows the injury, it is sometimes difficult 
to determine at what precise point the fracture has occurred; and it is 
generally still more difficult to say whether the fracture is oblique or 
transverse: indeed, this latter question is sometimes decided approxi- 
mately by a reference to the age of the patient rather than by the ex- 
amination of the limb. 

The immediate shortening varies from half an inch to an inch and a 
half, or even more; and it will average about one inch in the case of 
healthy adults. 

Prognosis. — Whatever may have been the general opinion of experi- 
surgeons as to the question of shortening in other fractures, very 
few certainly have ever claimed that in fractures of the femur a com- 
plete restoration of the bone to its original length was generally to be 
expected. There seem, however, to have existed only certain vague and 
indefinite notions as to the proportion and amount of this shortening, and 
which have had for their basis nothing better than a few imperfectly 
analyzed ol - 

Says Scultetus (quoting first from Hippocrates): "'For the bones of 
the thigh, though you do draw them out by force of extension, cannot be 
held so by any hands; but when the first intention slacks, they will run 
ber again : for here tli<- thick and strong flesh are above binding, 
and binding cannot keep them down." — Hippocrates de fract. Which 
Celsus seems to confirm, lib. 8, cap. 1". where li<' writes as follows of the 
cure of Legs and thighs: • For we musl not Ik- ignorant that if tli<" thigh 
be broken, that it will be made shorter, because it never returns to its 



460 FRACTURES OF THE FEMUR. 

former state." And Avicenna, lib. 4, fen. 5, saith 'that it is a rare 
thing for the thigh once broken to be perfectly cured again.' 

"These words admonish us," continues Scultetus, u that we should 
never promise a perfect cure of the thigh ; but rather, using all diligence, 
we should foretell that it is doubtful that the patient will be always lame ; 
but when this shall happen from the nature of the fracture, or, which 
most frequently falls out, from the impatience of the sick person, it may 
be imputed to our mistake, and, instead of a reward, bring us disgrace." 1 

Says Chelius : " Fracture of the thigh-bone is always a severe acci- 
dent, as the broken ends are retained in proper contact with great diffi- 
culty. The cure takes place most commonly with deformity and short- 
ening of the limb, especially in oblique fractures, and those which occur 
in the upper and lower third of the thigh-bone. Compound fractures 
are so much more difficult to treat." 2 

Says John Bell : u The machine is not yet invented by which a frac- 
tured thigh-bone can be perfectly secured." And Benjamin Bell de- 
clares that "an effectual method of securing oblique fractures in the 
bones of the extremities, and especially of the thigh-bone, is perhaps 
one of the greatest desiderata of modern surgery." "In all ages," he 
adds, " the difficulty of this has been confessedly great ; and frequent 
lameness, produced by shortened limbs arising from this cause, evidently 
shows that we are still deficient in this branch of practice." 3 

Velpeau says that "after fractures of the femur there is no limping 
unless the shortening exceeds three-quarters of an inch ; and the same 
is true if the shortening occurs in the tibia." The reason is, that the 
pelvis inclines toward the shorter limb, and thus compensates for the 
deficiency in length. In speaking of the various contrivances for dress- 
ing the fractured femur, he remarks that " most of them fail to obviate 
the shortening, and produce eschars, anchylosis, or troublesome arrests 
of the circulation. This is the price that is usually paid for the employ- 
ment of these complicated machines, and a shortening of a quarter to 
three-quarters of an inch is not avoided after all. The simplest appa- 
ratus that will maintain the adjustment of the fractured femur, so that 
union may take place with shortening of only half an inch, is the best." 4 

^elaton holds the following language : 

•• A fracture of the body of the femur, with an adult, is ahvays a grave 
accident, inasmuch as it demands so long a confinement to the bed, and 
especially on account of the shortening of the limb, which it is almost 
impossible wholly to prevent ; accordingly, Boyer recommends to the 
surgeon, from the first day, to announce to the parents of the patient 
the possibility of this accident. With infants, on the contrary, it is 
almost always easy to avoid the shortening." 5 

1 The Chirurgeon's Storehouse, by Johannes Scultetus, a Famous Physician and 
Chirurgeon of Ulme in Suevia. London, 1647. 

2 System of Surgery, by .1. M. Chelius, translated, etc., by South. First Amer. 
ed., vol. i. p. 627, 1847. See also p. 625, paragraph 679. 

; System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801. 

4 Peninsular Jourri. of Med., vol. ii. p. 384; also Memphis Med. Journ., vol. iv. 
p. 254, 1856. 

5 Klemens de Pathologie Chirurgicale, par A. Nelaton, torn. prem. p. 752. Paris, 
1844. 



FEACTURES OF THE SHAFT OF THE FEMUR. 461 

While Malgaigne declares his opinion on this subject thus, at length : 

•• When we do not succeed in drawing back the misplaced fragments, 
end to end, so that they may oppose themselves to the action of the 
muscles, it is impossible to preserve to the member its normal length, 
whatever may be the appareil or method employed. Surgeons are not 
sufficiently agreed upon this question. 

"At a period quite recent, Desault pretended to cure all fractures 
without shortening, and his journal contains several examples. In imi- 
tation of Desault, various practitioners have modified, corrected, and 
improved the apparatus for permanent extension, and they claim to have 
themselves obtained as complete success. I ought then to declare here, 
in the most positive manner, that I have never obtained like results, 
either in the use of my own apparatus, or with that of others, nor indeed 
where, in pursuance of my invitation, several inventors have applied 
their apparatus in my wards. I have examined, more than once, persons 
declared cured without shortening, and yet, upon measurement, the 
shortening was always manifest. The misfortune of all those who 
believe that they have obtained those miraculous cures is, that they have 
not even thought of instituting a comparative measurement of the two 
limbs : I will say even more, that they are most generally ignorant of 
the conditions of a good and faithful measurement. Sometimes, also, 
they have been deceived in another way — in falling upon fractures which 
were not displaced, especially with young persons ; and they have believed 
that they have cured with their apparatus a shortening which had never 
existed. In short, when the fragments are not displaced, or even when 
they are brought again into contact and maintained by their reciprocal 
denticulations, it is easy to cure the fracture of the femur without shorten- 
ing; aside of those two conditions, the thing is simply impossible. 

■• Several distinguished surgeons of our day have acknowledged this 
impossibility, and have renounced, in consequence, permanent extension. 
They allege, moreover, that an overriding of even three centimetres is 
of little importance, and occasions no limping. I cannot agree with this 
opinion. I have seen persons walk very well with a shortening of one 
centimetre ; beyond this limit, either they limp, or they have lifted the 
heel of the shoe. or. in short, the limping is only concealed by a lateral 
deviation of the spine. 1 We thus are made to comprehend how a frac- 
ture with overlapping is always serious, and how cautious we ought to be 
in our prognosis." 2 

That the foregoing remarks are intended by the author to be equally 
applicable to other fractures of the shaft of the femur as to those of the 
middle third, is made evident by what he has said before, when speaking 
of fractures of* the upper third : 

"The prognosis is sufficiently favorable when the fragments are den- 
ticulated (engrenees); when they ride, on the contrary, we must look for 
;i shortening ;i- almost incviTnble.'" 3 

1 Dr. Buck, of New York, thinks that with a shortening <>f one inch, or even one 
inch and a half, the patient may have ' ; :i useful limb, with little or no halting in 
his pait." N". Y. Journ. of Med., vol. xvi. p. 294. 

2 Traite d« • Luxations, par J. M. Malgaigne, torn. prem. pp. 723, 
724. Paris, 1847. 

3 Op. cit., p. 718. 



462 FRACTURES OF THE FEMUR. 

In our own country several of the most distinguished surgeons have 
testified to the constant difficulty, if not impossibility, of curing fractures 
of this bone without a shortening. In a suit instituted against a sur- 
geon in New York City, for alleged malpractice in the treatment of an 
oblique, comminuted, and otherwise complicated fracture of the femur 
near its condyles, Dr. Mott is reported to have testified that "more or 
less shortening of the limb is uniformly the result after fractured thigh, 
even in the most favorable circumstances." 1 

In a very interesting communication made to the author by Jonathan 
Knight, of New Haven, late President of the American Medical Asso- 
ciation, occurs the following passage : 

" I have seen but few fractures of the femur in the adult, unless of 
the most simple kind, in which there was not some remaining deformity ; 
often slight, so as not to impair the usefulness of the limb, and in others 
considerable and apparently unavoidable." Dr. Knight adds, however: 
" In the greater proportion of the fractures in children the recovery has 
been so nearly perfect that no marked deformit}^ or lameness has fol- 
lowed." 

Dr. Detmold, in his remarks made before the New York Academy 
of Medicine, at its meeting in March, 1855, declared his belief that a 
shortening of the femur always occurs after fracture, and that " but one 
inch of shortening in an average of twenty cases is a good result." 2 

Dr. J. Mason Warren, of Boston, writes to me as follows : "As you 
are making observations on fractures, I would state that, after a long 
and very careful observation, I have never yet seen, either in Boston or 
elsewhere, an oblique fracture of the thigh, in a patient over seventeen 
years of age, in which there was not some shortening. I have had cases 
shown to me in which it was averred that the limb was not shortened, 
but on measuring myself I have found the fact otherwise. In children, 
I believe that union without shortening may be accomplished." 

Dr. Bigelow, of the Massachusetts General Hospital, writes to me, 
May, 1875, as follows : " In our hospital cases shortening is the rule in 
adults. Young subjects do better. Three-quarters of an inch shorten- 
ing in the adult is a good result, and easily compensated by the pelvis. 
Greater shortening may occur. 

In a paper published by Dr. Lente in the number of the New York 
Journal of Medicine for September, 1851, he states that he believes the 
average shortening after treatment in the New York City Hospital to 
be three-quarters of an inch ; but subsequently, Dr. Buck, one of the 
hospital surgeons, has furnished Dr. Lente with more exact statistics. 
Says Dr. Buck : 

" After carefully scrutinizing over one hundred cases of fracture of 
the femur, taken from the register of the New York Hospital, and elimi- 
Dating such as involved the cervix, or condyles, or belonged to the class 
of compound fractures, there remained an aggregate of seventy-four 
cases, of both sexes, and of all ages from 3 to 63, in which the shaft of 

1 Boston Med. and Suig. Journ., vol. xxxiv. p. 450. See also opinions of Drs. 
Reese, Post, Parker, Cheeseman. Wood, etc., in relation to the prognosis in this par- 
ticular case. 

New York Journ. of Med , second series, vol. xvi. p. 261. 



FRACTURES OF THE SHAFT OF THE FEMUR. 463 

the femur alone was fractured." In all these cases the difference in 
the length of the fractured limb, resulting from the treatment, was ascer- 
tained by careful measurement with a graduated tape, and the following 
deductions were drawn from the analysis : 

••Of the 7-4 cases of all ages, 19 resulted without any shortening, a 
proportion of about one-fourth. The average shortening of the remain- 
ing do cases was a fraction less than three-fourths of an inch. 

•• Seventeen cases in the above aggregate were under 12 years of age, 
of which six resulted without any shortening, a proportion of about one- 
third. The average shortening in the remaining eleven cases was a 
fraction less than one-half an inch. 

" Of the 57 cases over 12 years of age, 18 resulted without any 
shortening, a proportion of about one-fourth ; and the average shorten- 
ing in the remaining 44 cases was a fraction over three-fourths of an 
inch." 1 

Mr. Holthouse, surgeon to Westminster Hospital, states that a careful 
examination of fifty cases of fractures of the femur in the various 
London hospitals, made by himself, showed that 90 per cent, (including 
twenty children) were shortened, the amount of shortening ranging from 
one-half an inch to three and one-third ; and as some of these cases were 
still under treatment, he entertains a doubt whether the final result will 
prove to be as favorable as above stated. For himself he declares, with 
a frankness which is most creditable to his courage and honesty, that at 
"Westminster, with all the appliances known to surgery at his command, 
he has never succeeded, in the adult, in effecting union without shorten- 
ing. He has also examined more than one hundred specimens in the 
various museums of the metropolis, and they are all shortened. 

After quoting the opinions of several writers upon this subject, includ- 
ing the author of this treatise, Mr. Holthouse adds in a footnote : 

•• Notwithstanding this strong testimony, surgeons are still to be found 
hardy enough, or ignorant enough, to repeat the fallacies which have 
been so often refuted, and to vaunt their success in the cure of oblique 
fractures in the adult without shortening. Why do not these surgeons, 
instead of publishing their cases in the journals, produce their patients 
ne of the medical societies?" 2 

Dr. Agnew, 8 after referring to these statements of Mr. Holthouse, 
: "My owd experience accords entirely with these statements. I 
have not met with a single case among all the specimens in Philadelphia 
of fracture of the shaft of the femur, which was entirely free from de- 
formity ; and I am equally certain that neither in hospital, nor in private 
practice, save in the case of children, have I ever succeeded in curing a 
case without an appreciable deformity." 

It is not to be denied, however, that a few surgeons in all parts of the 
world have claimed, and -til] continue to claim, in their own practice, or 
from the adoption of their own peculiar plans of treatment, much better 
success, [ndeed, some of them do not hesitate to affirm that, as ;i L r *'n- 
eral rule, any degree of shortening is quite unnecessary. 

1 Buffalo Med. Journ., vol ■. •. p. 22, -I'm,.-. 1869. 

2 Holthoua . of Surgery, 2d ed., 1870, vol. ii. p. 866. 
1 Agnew, Principle- andPractu*- of Surgery, vol. j. p. 948. 



4(U FRACTURES OF THE FEMUR. 

Mr. Amesbury declares, that when the fracture is in the middle or 
lower third," under a "judiciously managed" application of his own 
splint, tl consolidation of the bone takes place without the occurrence of 
shortening of the limb, or any other deformity deserving of particular 
notice." 1 

Mr. South, in a note, commenting upon an opposite sentiment ex- 
pressed by Chelius, and already quoted, remarks: "In simple fractures 
of the thigh-bone, except with great obliquity, I have rarely found diffi- 
culty in retaining broken ends in place, and in effecting the union with- 
out deformity, and with very little, and sometimes without any,- short- 
ening. For the contrary results the medical attendant is mostly to be 
blamed, as they are usually consequent upon his carelessness or igno- 
rance." 2 

Mr. Hunt, of the Queen's Hospital at Birmingham, w T ho treats all frac- 
tures with the apparatus immobile of Seutin, has published the results of 
his observations ; and of the simple fractures of the femur only one pre- 
sented, after the cure, any degree of shortening ; and he adds that all 
other fractures which he has treated by this method were followed by 
" equally good results." 3 In relation to which statements, Mr. Gamgee 
exclaims : " This is conservative surgery. What other mode of treat- 
ment would have given such results ? And those cases are not excep- 
tional. Mr. Hunt tells us that he has selected them from amongst many 
others equally successful. They accord w T ith the experience recorded in 
my little treatise on this subject ; and the works of Seutin, Burggrseve, 
Crocq, Velpeau, and Salvagnoli Marchetti record numerous cases no less 
remarkable and demonstratively conclusive." 4 

Desault, also, according to the passage from Malgaigne which I have 
already quoted, " pretended to cure all fractures without shortening." I 
do not find, however, any other authority for this statement, as here 
made; neither in his Treatise on Fractures and' Luxations, edited by 
Bichat, nor elsewhere. Bichat even says positively that " Desault him- 
self did not always prevent the shortening of the limb." 5 He declares, 
however, that " Desault has cured, at the Hotel Dieu, a vast number of 
fractures of the os fern oris, without the least deformity." 6 

Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault, 
as modified by Physick and Hutchinson (Fig. 152), was equally suc- 
cessful. 7 

Attention has already been called, in the chapter on General Prog- 
nosis, to the published statements of Dr. Sayre relating to this subject ; 
but it will be necessary to note again in this place, that he asserts that 
all fractures of the femur may be made to unite without shortening ; and 

1 Practical Remarks on Fractures, bv Joseph Amesbury, vol. i. p. 384. London 
ed., 1831. 

2 Op. cit, vol. i. p. 627. 

3 Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson 
Gamgee. London ed., pp. 159, 160. 

4 Op. cit., p. 167. 

5 A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav. 
Bichat. Amer. ed., p. 251. 1805. 

,; Op. cit., p. 223. 

7 Elements of Surgery, by John Syng Dorsey, vol. i. p. 163. Philadelphia, 1813. 



FRACTURES OF THE SHAFT OF THE FEMUR. 465 

to add that, in proof of the latter assertion, Dr. Sayre, at the meeting of 
the American Medical Association in Detroit, Michigan, in 1874, de- 
clared, when the accuracy of his measurements were called in question 
by some of the gentlemen present, that ' k he knew his measurements 
were correct, that Dr. Frank Hamilton had made the measurements, and 

Fig. 152. 



Physick's splint. — The splint is intended to reach to the axilla, but the counter-extension is 
made by a perineal band. Physick employed a second long inside splint. 

that he was a man who was so violently opposed to the theory that, in 
his published writings, he had denied the possibility of any oblique frac- 
ture being cured without shortening. For this reason he (Dr. S.) had 
asked him to measure the patients. He said if seven successive cases 
would be presented, he would agree to give up his opposition to the 
theory. He found the cases and surrendered." 1 

I was not present when these statements were made, but in the follow- 
ing number of the same journal in which they first appeared I called 
attention to their untruthfulness. And I will now repeat that I have 
never said, in any of my published writings or elsewhere, that it was im- 
possible that any oblique fracture of the femur could be cured without 
shortening, and I never entertained such an opinion ; but, while I have 
my.-elf published several cases in which oblique fractures of the femur 
treated by me have united without shortening, I have declared this to be 
the exception, and not the rule. Further, I am obliged to say that no 
Buch conversation as that related by him ever occurred between us, and 
that I never measured or saw the cases mentioned by him. It is difficult 
for me to conceive, therefore, how this gentleman has fallen into these 
errors; and I confess I would have been very much gratified if, his 
attention having been repeatedly and publicly through the medical jour- 
nal- called to the matter, he had made some such public explanation or 
denial as would have rendered it unnecessary for me to allude to it in 
this place. 2 

Dr. Scott, of Montreal, Professor of Clinical Surgery in the McGill 
College and Physician to the Montreal General Hospital, lias reported 
nineteen cases of fractures of the long bones, taken promiscuously and 
without selection, from his hospital service, of which three belonged to 
the clavicle, seven to the femur, eight to the tibia and fibula, and one to 
the condyles of the humerus. All of which recovered without any de- 
gree of shortening or deformity; except the case of fracture of the con- 
of the humerus, which resulted in death. 3 

It is never a pleasant duty to call in question the accuracy of anoth 
nents ;<- to what he has himself alone seen and experienced. The 
circumstances which would justify such an expression of* scepticism, 

1 Sayre, Detroit Review of Med., July, 1874. 

- li - : • i. 5. and Archives of Clinical - ril 11,1878. Editorial. 

3 Scott, "Medical Chronicle," of Montreal, vol. i. No. 7. If 

30 



466 FRACTURES OF THE FEMUR. 

where the witnesses, as in this case, are presumed to be intelligent and 
honest men, must be extraordinary. Such, however, I conceive to be 
the circumstances in this instance. It is certainly very extraordinary 
that a few gentlemen, whose means and appliances are concealed from 
no one, are able to do what nearly the whole world besides, with the 
same means, acknowledges itself unable to accomplish. Such is the 
fact, nevertheless ; and our lack of faith in their testimony is only a 
necessary result of our experience, and of the experience of the vast 
majority of practical surgeons, as opposed to them. 

I might properly enough dismiss this subject with no farther argument 
than may be found in the overwhelming testimony of practical surgeons, 
that broken femurs do in their experience rarely unite without more or 
less shortening ; but I cannot avoid calling attention to the evidence of 
the falsity of the opposite opinion, which is furnished by the testimony 
of the very persons who themselves claim to have obtained such fortunate 
results. 

It is not, as might have been supposed, one particular form of dress- 
ing, which, in itself peculiar, and more perfect than all others, has fur- 
nished these results. On the contrary, the plans of treatment have been 
constantly unlike, and sometimes quite opposite. Thus, Desault used a 
straight splint, with extension and counter-extension, and he refused to 
adopt the flexed position recommended by Pott, because his experience 
and the experience of other French surgeons had taught him its in- 
utility. 1 Adopting the straight position, he made perfect limbs ; with 
the flexed position he found it impossible to do so. 

Dorsey used the splint of Desault, as modified by Physick and Hutch- 
inson. Say re, who formerly used the double- or triple-inclined plane, 
or flexed position, has of late adopted the straight position, with plaster 
of Paris, and with both alike claims to have made only perfect limbs. 

South, whose success seems to have been equal to that of Desault or 
Dorsey, adopts also the straight position : but he makes no permanent 
extension, except what may be accomplished through the medium of four 
long side-splints applied after "gentle" extension has been made by the 
assistants. 

Mr. Amesbury, on the other hand, made perfect limbs only with his 
own double-inclined plane ; and speaking in general of the various plans 
hitherto contrived, not excepting that invented by Desault, or the method 
practised by South, which had already been recommended by several 
surgeons, he declares that " they are seldom able to prevent the riding 
of the bone, and preserve the natural figure of the limb. Indeed, so 
commonly does retraction of the limb occur under the use of the differ- 
ent contrivances usually employed, that I have heard a celebrated lec- 
turer (now retired) in this town publicly assert that he never saw a frac- 
tured thigh-bone that had united without riding of the fractured ends!" 2 
And in his G-eneral Inferences he uses the following emphatic language : 
" The contrivances which are commonly used in the treatment of these 
fractures do not sufficiently resist the operation of the forces above 

1 Works of Desault, op. cit., p. 225. 

2 Amesbury on Fractures, etc., vol. i. p. 310. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



467 



mentioned, but suffer their influence to be exerted upon the bone, in all 
eases more or less injuriously, and at the same time often assist in pro- 
ducing displacement of the fractured ends ; so that deformity, differing 
in kind and degree in different cases, is almost the constant result of 
fractures of the femur treated by these means." 1 

On the other hand. Mr. Gamgee broadly contradicts the statements of 
Desault. South, Dorsey. and Amesbury, and does not hesitate to admin- 
ister a severe rebuke even upon the illustrious Listen: "Pott's plan, the 

Fig. 153. 




Liston's method, recommended by Samuel Cooper, Fergusson, Pirrie, and others. 

long splint. Mclntyre, and their modifications, as a rule entail sensible 
deformity, which in many cases is very considerable. It is a significant 
fact that though the example established in University College Hospital 
by the late Mr. Liston, of treating fractures of the thigh by the long 
splint, and of the leg by the modified Mclntyre (a double-inclined plane), 
which are admitted equal, if not superior, to other splints, was rigidly 
followed in that institution, the patients admitted with broken thighs or 
ere frequently discharged with manifest deformity.'" 2 

With how much force Mr. Gamgee's own remarks as to the experience 
of the University College Hospital will apply to the starched bandages 
used by himself, the reader will be able to determine when referred to 
the opinion of Velpeau, already quoted, who claims no result better than 
an average shortening of half an inch. M. Velpeau prefers and advo- 
cates the starched bandages, but he does not claim to be able to prevent 
a shortening of the bone. 

-What other modes of treatment would have given such results?" 
This question, propounded, no doubt honestly, by Mr. Gamgee, has here 
it- fair and satisfactory answer. Almost any of the various modes 
named: for if we must receive his testimony, we are equally bound to 
receive the testimony of Desault, South, Dorsey, Amesbury, Scott, and 
Sayre. If we give credit to Mr. Gamgee, so far as to doubt the state- 
ments of these latter as to the degree of success claimed by them, by the 
same rule we must doubt hie own statements also as to the degree of 
Baccess claimed by himself. This 1 say with all sincerity and kindness, 
fully believing that these gentlemen are mistaken, and not that they 
intentionally misrepresent the facts. 

By a reference to my Report on Deformities after Fractures, it will 
n that the average shortening in fractures of the upper third of 



1 Op. cit., vol. i. | 

2 Advanta^- of the .Starched Apparatus, by Joseph Sampson Gamgee. 
1853, pp. 54. 55. 



London. 



468 FRACTURES OF THE FEMUR 

the femur, in the cases examined by me, was about four-fifths of an inch; 
in the lower third it was a, fraction over three-quarters, and in the middle 
third a fraction less than three-quarters of an inch; and the average of 
the whole number was almost exactly three-quarters of an inch ( three- 
quarters* and one forty-seventh). These analyses were made upon simple 
fractures, and were exclusive of those in which no shortening at all oc- 
curred. An analysis which included also those which had not shortened, 
reduced the average shortening to half an inch and about one-tenth. 

An examination of cabinet specimens does not present a result so 
favorable even as this. Of nineteen fractures of the shaft of the femur 
contained in Dr. Miitter's cabinet, not one se'ems to have been shortened 
less than one inch. Specimen B 63, fracture of the middle third, is 
united with a shortening of two inches and a quarter ; and specimen B 
130, imperfectly united after a fracture through the middle third, is over- 
lapped three and a half or four inches. 

In conclusion, I wish to say briefly that, in view of all the testimony 
which is now before me, I am convinced — 

First. That in the case of an oblique fracture of the shaft of the 
femur occurring in an adult, whose muscles are not paralyzed, but which 
offer the ordinary resistance to extension and counter-extension, and 
where the ends of the broken bone have once been completely displaced, 
no means have yet been devised by which an overlapping and conse- 
quent shortening of the bone can generally be prevented. 1 

Second. That in a similar fracture occurring in children or in persons 
under fifteen or eighteen years of age, the bone may quite often be made 
to unite with so little shortening that it cannot be detected by measure- 
ment ; but it must not be forgotten that with children especially it is 
exceedingly difficult to measure very accurately. 

Third. That in transverse fractures, or oblique and denticulated, oc- 
curring in adults, and in which the broken fragments have become com- 
pletely displaced, it will generally be found equally difficult to prevent 
shortening ; because it will be found generally impossible to bring the 
broken ends again into such apposition as that they will rest upon and 
support each other. 

Fourth. That in all fractures, whether occurring in adults or in chil- 
dren, where the fragments have never been completely or at all displaced, 
constituting only a very small proportion of the whole number of these 
fractures, a union without shortening may always be expected. 

Fifth, That when, in consequence of displacement, an overlapping 
occurs, the average shortening of simple fractures in adults, where the 
best appliances and the utmost skill have been employed, is from one- 
half to three-quarters of an inch. 

1 In the three first editions of this treatise the word " generally " is omitted ; but a 
later experience, with improved appliances, has supplied to me, both in my own 
practice and in the practice of others, a few examples of perfect union under the con- 
ditions named. The word "generally" wis therefore added in the fourth edition, 
and is retained in this. Exactly what percentage of perfect cures may reasonably be 
expected cannot at present be determined, but it is certainly very small. It has 
never been my opinion that a shortening must inevitably result as a consequence of 
the absorption of the ends of the bone. When shortening occurs I think it is always, 
or almost always, the result of overlapping of the fragments. 



FRACTURES OF THE SHAFT OF THE FEMUR. 469 

If we consider the muscles alone as the cause of the displacement in 
the direction of the long axis of the shaft, the shortening of the limb, 
other things being equal, must be proportioned to the number and power 
of the muscles which draw upwards the lower fragment. This will vary 
in different portions of the limb, but nowhere will this cause cease to 
operate, nor will its variations essentially change the prognosis. 

I have not intended to say that other causes do not operate occasion- 
ally in the production of shortening, but only that muscular contraction 
is the cause by which this result is chiefly determined, and that its power 
will be ordinarily the measure of the shortening. 

Conditions of a Faithful Measurement of the Thigh. — The fact that 
a patient walks without any halt, is no evidence that the limb is not 
shortened. In this regard patients are very unlike ; one having a short- 
ening of only half or three-quarters of an inch may limp perceptibly, 
while another with a shortening of an inch, or even an inch and a half, 
may not limp at all. This has been frequently observed ; and it will be 
easily understood if, standing erect with the right foot on a block one 
and a half inches in height, the left foot is planted upon the floor. It 
will then be seen that the left foot can be brought to the floor without 
disturbing the erect position of the body. Nor is it any more a proof 
that the limb is not shortened because, while in the recumbent posture, 
the heel can be brought down to the level of the other. 

Measurements made from the umbilicus, or from the symphysis pubis, 
are always indefinite and unreliable. Velpeau's idea of measuring from 
the folds of the belly, immediately above the ilium, is unsound. Mr. 
Bryant's suggestion that we measure from the trochanter major, by what 
he terms the ilio-femoral triangle, in order to determine the question of 
a fracture of the neck, is liable to the very serious objection that the 
exact position of the top of the trochanter cannot, in most cases, be 
clearly determined. 

The method most generally practised, is to measure from the round 
end of the anterior superior spinous process of the ilium to the internal 
or external malleolus ; but even this is not very trustworthy. It is 
exceedingly difficult to note accurately the same point upon the two 
: and an error of half an inch is very common when this method is 
adopted. 

The patient should repose upon his back, upon an even surface, with 
the lower extremities as nearly as possible in line with the axis of the 
body, the two wings of the pelvis being in the same (horizontal) line. 
A flexible, but firm, graduated tape is to be preferred to the steel tape 
measure. The foot being steadied by an assistant, the surgeon should 
put hia thumb-nail against the line where it joins the ring, and push hi- 
nail into the -kin just below the anterior superior spinous process of the 
ilium, pressing firmly up and back, the flat surface of the nail resting 

Upon the skin. In this way he will obtain a fixed point, and lie can 

obtain an exactly corresponding point upon the opposite side. Below, 
the measurement may be made from either malleolus, but the outer lias 
the most defined extremity, and is generally to be preferred. In most 
-. for some months after the termination of the treatment, there is 
some swelling about the ankle, which renders i> necessary to use great 



470 



FKACTURES OF THE FEMUR. 



care in defining the point of the malleolus. The thumb-nail of the oppo- 
site hand may be used for this purpose, resting vertically upon the skin 
(flat against the lower end of the malleolus). The same method may be 
employed in measuring a leg, as in measuring a thigh. 

Dr. B. F. Gibbs, of the U. S. Navy, and Dr. S. B. Collins, of Phila- 
delphia, have recently suggested and employed mechanical apparatus, of 
ingenious construction, for the purpose of rendering these measurements 
more accurate ; x but neither of them is sufficiently simple to be brought 
into general use, except in hospitals and dispensaries. 

Allusion has already been made in the chapter on General Prognosis 
to the fact that the bones of the lower extremities as well as other long 
bones are not always, nor perhaps generally, in the normal condition, of 
exactly equal lengths. J. G. Garson, of London, in the examination of 
seventy skeletons, ranging from twelve years upwards, found only ten 
per cent, which were of exactly equal length. 2 Corydon La Ford, Pro- 
fessor of Anatomy at Ann Arbor, however, in the measurement of 
skeletons, found the inequality of the length of the lower limbs excep- 
tional rather than as constituting the rule. Garson and Wight agree 
that the left leg was most often the longest. In Garson's measurements 
the left leg was longest in 38 cases, and the right in 25 cases. In most 
cases these differences are slight, but occasionally they are considerable. 
As to the practical deductions to be made from this fact of asymmetry, it 
has been sufficiently considered in the chapter on General Prognosis. 

Treatment. — All the early surgeons, so far as we know, adopted the 
straight position in the treatment of fracture of this bone, either with 
simple lateral splints, or with long splints, with or without extension, or 
with only rollers and compresses, or with extension alone. 

Such was the unanimous opinion and practice of surgeons until about 
the middle of the last century, at which time Percival Pott wrote his 
remarkable treatise on fractures, a work distinguished for the originality 
and boldness of its sentiments, and which was destined soon to revolution- 



Fig. 154. 




Double-inclined plane formerly employed in Middlesex Hospital, London. 

ize, especially throughout Great Britain, the old notions as to the treat- 
ment of fractures, and to establish in their stead, at least for a time, 
what has been called, not inappropriately, the "physiological doctrine," 
the peculiarity of which doctrine consisted in its assumption that the 

1 Gibbs, Collins, Amer. Journ. Med. Sci., Jan. 1877, pp. 139, 144. 

2 Garson, Amer. Journ. Med. Sci., Oct. 1879, from Journ. Anat. andPhys., July, 
1879, vol. 13, p. 502. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



471 



resistance of those muscles which tend to produce shortening can gener- 
ally he sufficiently overcome hy posture, without the aid of extension; 
and that for this purpose, for example, in the case of a broken femur, it 
was only necessary to flex the leg upon the thigh, and the thigh upon 
the body, laying the limb afterwards quietly on its outside upon the bed. 

Very few surgeons, even of his own day, ever gave in their full adhe- 
sion to the exclusive physiological system as taught and practised by Pott 
himself, but multitudes, especially among the English, adopted in gene- 
ral his views, only choosing to place the patients upon their backs rather 
than upon their sides, and laying the limbs flexed over a double-inclined 
plane. To the support of this system of Pott's, thus modified, Sir Astley 
Cooper, C. Bell, John Bell, Earle, White, Sharp, and Amesbury, lent 
the influence of their great names, and its triumphs, so far as the judg- 
ment of British surgeons was concerned, soon became complete. 

In France, and upon the continent generally, the reception of this sys- 
tem was more slow and reluctant ; but Dupuytren, now for once taking 

Fig. 155. 




Amesbury's splint. 

ground with his great rival, Sir Astley Cooper, adopted almost without 
qualification these novel views. The decision of Dupuytren determined 
the opinions of a large portion of the continental surgeons ; and had it 
not been for the early and decisive opposition of Desault and Boyer, the 

Fig. 156. 




Amesbury's splint applied. 

great surgeon of St. Bartholomew might have continued for a long time 
to have enjoyed a triumph upon the continent, and perhaps throughout 
the world, equal to that which had already been decreed to him in Great 
Britain. 

On this side of the Atlantic, the practice of Pott, at least in so far as 
it applied to the treatment of fractures of the thigh, never gained ;• dis- 



47:2 FRACTURES OF THE FEMUR. 

tinguished advocate; and but few ever adopted the practice as modified 
by White, Amesbury, Bell, A. Cooper, etc. 

But whatever may have been the early success of these doctrines, 
either here or elsewhere, it is certain that a strong reaction has taken 
place, and that gradually, in all parts of the world, the opinions of prac- 
tical surgeons have been settling back into their old channel. It would 
be difficult to find to-day, in France or Germany, a dozen distinguished 
surgeons who adopt universally the flexed position in the treatment of 
fractures of the femur ; and in England the reaction is, if possible, even 
more complete. 

Fig. 157. 




Boyer's splint. 



In my tour of 1844, during w T hich I visited very many of the hospitals 
of Great Britain, and upon the continent of Europe, and in my later tour 
of 1872, I do not remember to have seen the flexed position once em- 
ployed in the treatment of a broken thigh; and I shall presently show 
that the straight position is at the present moment very generally adopted 
by the best American surgeons. 

There have been, then, three grand epochs in the history of the treat- 
ment of fractures of the thigh. 

First. That in which the straight position was universally adopted, and 
which reaches from the earliest periods to the period of the writings of 
Pott, or to about the middle of the last century. 

Second. The epoch of the flexed position, which, inaugurated by Pott, 
had already begun to decline at the beginning of the present century, 
and which may be said to have been completed within less than one 
hundred years from the date of its first announcement. 

Third. The epoch of the renaissance, or that in which surgeons, by 
the vote of an overwhelming majority, have declared again in favor of 
the straight position. This is the epoch of our own day. 

Although American surgeons have generally adopted the straight 
position in the treatment of fractures of the thigh, yet the form and 
construction of the splints employed have been greatly varied. The 
simple long splint of Desault, and the more complicated apparatus of 
Boyer (Fig. 157) have each had their advocates ; but it is seldom that we 
meet with these, or with any of the other forms of apparatus originally 
employed in foreign countries, without noticing that they have been 
subjected to considerable modifications ; indeed, most of the straight 
splints as well as double-inclined planes in use at present among Ameri- 
can surgeons may fairly be regarded as original inventions. 

Nathan Smith, of New Haven ; l Nathan R. Smith, of Baltimore ; 2 

1 Amer. Med. Rev., Philadelphia, 1825, vol. ii. p. 355; also Medical and Surgical 
Memoirs of Nathan Smith, pp. 129-141. 

2 Med. and Surg. Memoirs, )»]>. 1 4'i— 1 62. See also Geddings, Baltimore Med. and 
Surg. Journ., vol. i., 1833 ; and Sargent's Minor Surgery, p. 171. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



473 



Dr. James McNaughton, of Albany; 1 J. T. Hodgen, of St. Louis: and 

Nott, of Mobile, are the only American surgeons of distinguished repu- 



Fig. 158. 




Nathan R. Smith's suspending apparatus, or double-inclined plane. 

tation. and with whose practice I am familiar, who have recommended 
exclusively the double-inclined plane. 

Fig. 159. 



h^ 




Josiah C. Xott's double-inclined plane. 
In this apparatus the limb is secured to the splint by vertical pins and leather straps: the 
upper surface of the thigh-splint is carved out a little, to fit the thigh: the two portions are 
articulated by a joint like that of a carpenter's rule, and this joint may be steadied by a 
horizontal bar underneath. For the rest, the drawing sufficiently explains itself. 

Dr. Nathan R. Smith has introduced a modification of the double- 
inclined plane in what is known as his "anterior splint," and which is 

160. 




\. EL Smith's anterior splint. 

intended also ;i- ;i suspending apparatus. I >aw it employed a _ 
deal in the treatment of gunshot fractures of the thigh and le'_ r in our 



1 Ti "]. \. j,. 817. Rep. on Defor. after Frac. 



474 



FRACTURES OF THE FEMUR. 



various military hospitals during the progress of the civil war, especially 
at the South. It is my opinion, however, that it is more applicable to 
gunshot fractures of the leg than to those of the thigh. 

The splint, if splint it can be properly called, is simply a frame com- 
posed of stout wire and covered with cloth, which, being suspended above 
the limb, allows the limb to be suspended in turn to it by rollers ; the 
rollers passing around both limb and splint from the foot to the groin. 
Wire of the size of No. 10 bougie is usually employed. The length of 

Fig. 161. 




X. R. Smith's anterior splint, applied for a fracture of the th 



the splint should be sufficient to extend from above the anterior superior 
spinous process of the ilium to a point beyond the toes, the lateral bars 
being separated about three inches at the top and one-quarter of an inch 
less at the lower extremity. 

In the case of a broken thigh, the upper hook, to which the cord for 
suspension is to be fastened, ought to be nearly over the seat of fracture, 
and the lower hook should be placed a little above the middle of the leg. 

The modification of Smith's anterior splint, suggested by Dr. James 
Palmer, United States Navy, will be sufficiently explained by the accom- 
panying woodcut, 1 Fig. 162. 

Dr. G. E. Porter, of Lonaconing, Maryland, who prefers N. R. 
Smith's apparatus, elevates the foot of the bed to insure counter-extension 
with the weight of the body, but in doing this he practically yields the 
point of allowing the patient to rise and sit in bed. He employs, also, 
strips of " stout, unstretching brown drilling," instead of the continuous 
roller. 2 

Dr. J. S. Hodgen, of St. Louis, Mo., has for many years employed a 
wire suspension splint, which I much prefer to Smith's. The bars of 

1 Amer. Journ. Med. Sci., 1865; also, Mechanical Therapeutics, etc., by Philip S. 
Wales, M.D., U. S. N., 1867. 

2 Porter, Med. and Surg. Reporter, March 18, 1876. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



475 



wire are traversed with a cotton sacking, upon which the limb is laid. 1 
I regret that in earlier editions, when referring to this apparatus, I 
have spoken of it as having been employed by Dr. Hodgen in gunshot 
fractures alone, while in fact it is employed by him in all, or nearly all 
fractures of the femur. The error came, probably, from the circum- 
stance that I had myself seen it used only for gunshot fractures. 

Fig. 162. 




Palmer's modification of the anterior splint. 

On the other hand, among the advocates of the straight position are 
found tli'- names of Physick, Dorsey, 'Gibson, Horner, J. Hartshorne, 
H. II. Smith, Neill, R. Coates, II. Sartshorne, Norris, Gross, Ashhurst, 
v. and Packard, of Philadelphia; Buck, Markoe, Stein, Post, 
. Ward, Weir, Mason, Sands, and Little, of New York, and many 
others. In this city I know of no surgeon who employs habitually the 
flexed position. 

3 Dr. ( fross: "Many years ago, before I bud much experience in 

this class of injuries, I occasionally employed the flexed position, bul I 

found that it was objectionable, en accounl of the greal difficulty in 

maintaining an accurate apposition to tie- ends of the fragments. ( )f late 

1 Hodgen, Treatise on Military Surgery, by F. IF Eamilton, 1866, )>. 411. 



476 



FRACTURES OF THE FEMUR. 



years I have confined myself entirely to the use of the straight position, 
and 1 have never had any cause to regret it. In the adult, I sometimes 
employ the apparatus of Desault, as modified by Physick, but much 
more frequently one of my own construction, somewhat upon the prin- 
ciple of that of Dr. Neill, described in the Philadelphia Medical Ex- 
aminer for 1855. I have used it for nearly twenty years, and it has 



Fig 




Hodgen's suspension apparatus. 

generally answered the purpose most admirably in my hands. It consists 
simply of a box for the thigh and leg, with a foot and two crutches, one 
for the axilla and the other for the perineum, to make the requisite ex- 




John Neill's straight thigh-splint. — Extension and counter-extension made at the same time. 



ten-ion and counter-tension. With such an apparatus, an oblique frac- 
ture of the thigh can be treated with great comfort to the patient, and 
with the assurances of a good limb. In children, I have effected some 



FRACTURES OF THE SHAFT OF THE FEMUR. 



477 



excellent cures simply by means of a sole-leather trough, well padded, 
and provided with a foot-piece. 

" The great objection to the flexed position is the difficulty of keeping 
the ends of the broken bones in apposition ; the upper one having a con- 
stant tendency to pass away from the inferior. Other objections might 
be urged against the flexed position, but this is quite sufficient to induce 
me to reject it." 1 

The following woodcuts, from Fig. 165 to 173 inclusive, illustrate the 
apparatus formerly used in the Massachusetts General Hospital, Boston. 
(From drawings furnished by Dr. L. M. Sargent.) 

Fig. 166. 





Pelvic belt and perineal strap. 



Foot-piece and screw. 



Fig. 167. 







Lateral view of the apparatus, without the belt. 
Fig. 168. 






\ 



Front view of the apparatus, with folded sheet laid across. 
Fig. 169. 




Apparatus applied. 



1 Trans. Am. Med. Assoc, vol. z. j also System of Surgerv, by S. D. Gross, 1869, 

p. 221. 



478 



FRACTURES OF THE FEMUR. 



" The belt is made of strong webbing, having pockets on each side, 
to receive the long splint. . It is also furnished with straps and buckles. 



Fig. 170, 




IP 1 ' 



Side view of apparatus applied. 
Fig. 171. 




Fig. 172. 




Fig. 173. 



Figs. 170, 171. Mode of making extension with adhesive plaster. 

The perineal strap (Fig. 173), corresponding to the injured side, is kept 
constantly buckled, while the other may be occasionally loosened, or left 
off, as its purpose is only to steady the appa- 
ratus. Where the straps pass under the peri- 
neum, they are covered with wash-leather. 
Before applying the belt, a pillow-case or two 
may be passed around the waist. The padlock 
is only to be used in case the patient persists in 
unbuckling the straps. The splints, being ap- 
plied (with also short side-splints, junks, con- 
taining bran or sand, etc.), are to be secured 
more firmly to the limb by bands of webbing 
and buckles." 

Dr. Bigelow informs me that Flagg's appa- 
ratus is not now in use at this excellent hospital, 
and has not been for some time ; but I have 
retained the illustrations because they exhibit 
much ingenuity, and serve to explain the gradual progress of improve- 
ment in the treatment of these fractures. 

At present the surgeons of the Massachusetts General Hospital em- 
ploy essentially the same apparatus which I at present employ and shall 
hereafter describe ; extension being made by a weight and pulley, with 
the aid of adhesive straps, and counter-extension being effected by the 
weight of the body, by elevating the foot of the bed. After which, 
coaptation splints and junks are applied in the usual manner. Ether is 




Perineal band secured with a 
padlock. (Flagg's apparatus.) 



FEACTUEES OF THE SHAFT OF THE FEMUR, 



479 



employed in all cases before making extension, the apparatus being ap- 
plied at the earliest possible moment. 

The late Dr. Xeill. of Philadelphia, contrived a very ingenious mode 
of both extension and counter-extension at the same moment, by means 
of a twisted rope, which is fastened by its two ends respectively to the 
perineal band above and the extending band below. (For illustrations 
of this apparatus see five first editions of this book.) 

The two Warrens, lather and son, of Boston ; Kimball, of Lowell ; 
Sanborn, of Lowell, Mass.: Mussey, of Cincinnati, Ohio; J. B. Flint, 
of Louisville. Ky. : Arnisby, of Albany : l Moore, of Rochester ; and 
Potter, of Batavia. have also recommended some form of the straight 
splint. Said the late Dr. Reuben D. Mussey : 

4 * For all fractures of the thigh-bone, I employ the extended position 
of the limb. There are but few cases in which extending force is not 
necessary to prevent the degree of deformity or shortening which would 
occur without it. Of thirty specimens of fracture of the shaft, in my 
collection, only two are transverse. In fractures of the neck, especially 
with old subjects, I sometimes avoid the application of any kind of appa- 
ratus for permanent extension ; but in all cases, whether of the neck or 
shaft, where such extension is attempted, I have found the straight 
position of the limb to be the most reliable." 

Daniell, of Savannah, Georgia, recommends the straight position, the 
limb being laid in a kind of long box, and the extension being made with 
a weight and pulley.' 2 Dugas, of Augusta, Georgia, employs the pulley 
and weight also, but uses the long side-splint instead of the box. 3 Howe, 
of Boston, recommended a similar method in 1824. 4 

Fig. 174. 




Gurdon Buck's apparatus, with perineal band of India-rubber tubing, and an elastic cord 
for ."-u-spending the weight. 

Dr. Gurdon Buck, of New York, used the pulley, without the long side- 
splint. His perinea] band was composed of India-rubber tubing, "of one 
inch calibre, two feet in length. " : stuffed with bran or cotton lampwick, 
and covered with canton flannel, which covering may be renewed as often 



1 Trar:-. Am. Med. Amoc., vol. x. Report on Deformities after Fractures. 

2 Daniell, Arner. Journ. Med. Sciences, vol. iv. p. 330, 1829. 

3 Dugas. Southern Med. and Surg. Journ., Feb. 1854. 
* Howe, New Bng. Med. Journ., Julv, 1824. 



480 



FRACTURES OF THE FEMUR 



as may be necessary; the extending bands or adhesive plasters termi- 
nating below the foot in an elastic rubber cord. (Fig. 174.) 

William E. Horner, of Philadelphia (Fig. 175), employed a long outside 
splint, extending into the axilla, and padded, so as to avoid the necessity 
of junks; with fenestra, for extending and counter-extending bands ; and 
also a foot-piece ; and a short inside splint, made to extend from the peri- 
neum to the bottom of the foot. Across the excavated upper end of this 

Fig. 175. 




W. E. Horner's thigh-splint. 



splint, a strip of leather is stretched to receive the pressure of the peri- 
neum, while the perineal band is made to pass through two firm leather 
loops on the outside of the splint. 1 



Fig. 176. 




Joseph E. Hartshorne's thigh-splint. 

Dr. Joseph E. Hartshorne, of Philadelphia (Fig. 176), rejected the 
perineal band altogether, and sought to make the counter-extension by 
means of the inside long splint alone ; and for this purpose he cushioned 
the head of the inside splint, as will be seen in the accompanying drawing. 
The head, of the outside splint may also be cushioned, but not for the pur- 
pose of employing it as a means of counter-extension. The outside splint 
is so adjusted to the foot-piece, that it may be removed in case of a 
compound fracture, without disturbing either the extension or counter- 
extension. 2 

Dr. David Gilbert, of Philadelphia (Figs. 177, 178), has published an 
account of a method of making counter-extension with adhesive strips, 
which he had employed not only in fractures of the thigh, but also of the 
leg, extension being made with the tourniquet of Petit. A broad piece 
of adhesive plaster also is made to encircle the pelvis, in order to bind 
down the counter-extending bands more firmly to the body. Additional 
strips are employed when they seem to be required. 3 

H. L. Hodge, also of Philadelphia, adopting the same means of 
counter-extension, namely, adhesive plaster bands, has modified the idea 

1 Horner, Treatise on the Practice of Surgery, by H. H. Smith, 1856, p. 417. 

2 Hartshorne, Ibid., p. 418. 

3 Gilbert, Amer. Journ. Med. Sci., April, 1859, pp. 410-424. 



FEACTCRES OF THE SHAFT OF THE FEMUR. 



481 



of Gilbert by securing the strips of plaster to the sides of the body instead 
of the perineum, and attaching them to an iron rod which is made to 
project from the top of the splint beyond the shoulder. 1 (Fig. 179.) 

Lente, of New York, many years ago, before the value of elevating 
the foot of the bed. and depending upon the weight of the body to make 



Fig. 1 




D. Gilbert's mode of making counter-extension and extension. 

1. Anterior and posterior counter-extending adhesive bands, two and a half inches wide, 
crossing each other before they pass through the mortise holes. 2. The same, crossing at 
the upper part of thigh and perineum. 3. Horizontal pelvic band, which may be three 
inches wide. 4. Extending bands, receiving strap of tourniquet in the hollow of the foot. 
5. Tourniquet. 

counter-extension, was understood, constructed an apparatus by which 
he hoped, in some measure, to obviate the inconveniences of the perineal 
band, by distributing the pressure between the tuberosity of the ischium 
and the groin. He, therefore, supplied his splint with an iron brace, 
extending in a curved line from the upper part of the external splint, 



Fig. ITS. 




Gilbert's apparatus applied in a case of fracture of both thighs. 

directly across the body, to the median line, and cushioned on its inner 
-urrace. To this is attached the anterior extremity of the perineal band. 
By this arrangement the pressure is not only in a great measure removed 
from the groin, and from tin- vessels, etc. on the inside of the thigh, but 
also the direction of the counter-extension is in a line with the axis of 
the body. The posterior extremity of this hand is secured, not to the 

1 Hodge, Arner. Journ. Med. Sci., April, 1860. 
31 



482 



FRACTURES OF THE FEMUR. 



ii|) per end of the splint, as is usually done, but to the splint several 
inches lower down, where it will take a more secure hold upon the under 
surface of the tuberosity and nates. Both extremities of the band are 
elastic. Extension is made with a screw, inclosing a strong spiral spring 



Fig. 179. 




H. L. Hodge's method of counter-extension in fracture of the femur. 

in its ferrule', or with adhesive plasters, a pulley and weight, at the option 
of the surgeon. 

Fig. 180. 




Lente's thigh-splint. 



The splint is made in sections, for adaptation to different persons, and 
for convenience in packing. It extends no higher than the alse of the 



FRACTURES OF THE SHAFT OF THE FEMUR. 



483 



pelvis, and is secured to the body at this point by a padded pelvic band. 
The accompanying illustration (Fig. 180) will sufficiently explain the 
remaining features of the apparatus. 

The apparatus invented by Dr. Burge, of Brooklyn, is both a fracture- 
bed and a splint, and was constructed with the same view of removing 
pressure from the front of the groin. The principles involved and the 
general plan of construction will be sufficiently explained by a study of 
the accompanying woodcuts. (Figs. 181, 182.) 

Fig. 181. 




Burge's apparatus. 

Dr. T. W. Simmons, of Hagerstown, Maryland, who declares that he 
is unable to see how extension can be made in the flexed position, has 
constructed a suspension apparatus for horizontal extension in fractures 



Fig 




Uurge's apparatus applied. 

of the lower extremities. It is composed of a suspending bar, two side 
splint-, and ;i foot-piece. (Fig. 183.) 

Tli'- suspending bar is made of iron, three feet long, one and ;i quarter 
inches wide in its vertical diameter, and three-quarters of an inch thick. 
It is furnished with slot-, and eyes for suspension. The two side-pieces 
or splints are of wood, long enough to extend from the malleoli to the 
body, tlf outer splints being extended above the ilium. They are sepa- 
rated from each other by two strong wire-, and suspended from the sus- 
pension bar by leather straps, which are made fasl to the bar by the aid 
of metallic ears, through which the straps pass, the metallic ears being 



484 



FRACTURES OF THE FEMUR. 



secured in the slots by thumb-screws, thus providing for adjustment and 
fixation. 

The apparatus is now suspended from the ceiling by two ropes, carried 
obliquely, as seen in the drawing, to the hook in tbe ceiling, and then 
brought down to the bed and tied. 

A bandage is then made to inclose the whole length of the splints, 
from the ankle to the groin, by continuous turns from side to side. 
Upon this the limb is laid, and then the foot is applied snugly to the 




T. W. Simmons's suspension-extension apparatus. 



foot-piece and made fast by long and wide adhesive strips laid the whole 
length of the leg and passed beneath the foot-piece ; this is to be reinforced 
by a roller if necessary. It may also be necessary to inclose the whole 
length of the splints, including the thigh and leg, in another roller. 
The long outside splint is secured to the body by a pelvic band or roller. 

Great care should be exercised in adjusting the bearings so that the 
limb does not fall to the one side or the other, and that the foot applies 
easily and at the proper angle to the foot-board. 

The same mode of suspension and extension may be employed in using 
a box or a plaster-of- Paris splint. 1 

At the " German Hospital," in this city, under the observation of the 
late Drs. Krakowizer and of Guleke, visiting surgeons, five cases are 
reported as having been treated by Buck's extension and one by plaster 

1 Simmons, Amer. Journ. Med. Sci., April, 1875. 



FRACTURES OF THE SHAFT OF THE FEMUR. 485 

of Paris. Buck's extension had given the best results. At the "Pres- 
byterian Hospital," also. Dr. P. M. Stimson reports that Buck's exten- 
sion is generally employed. Dr. Alfred C. Post says : 

" My ordinary practice is to treat fractures of the femur by exten- 
sion with a weight and pulley. The method seems to me as nearly 
perfect as any plan of human device can be, in promoting the comfort 
of the patient, in facilitating the urinary and fecal evacuations, and in 
securing union without deformity. In some cases union occurs abso- 
lutely without shortening, and in other cases the shortening is so slight 
as only to be detected by careful measurement. In cases carefully 
treated by this method it is rare to meet with shortening much exceed- 
ing half an inch. I have never seen a case of simple fracture of the 
femur treated in this way in which there was any such shortening or 
deformity as I have seen in some cases which have been treated by the 
use of plaster-of-Paris bandages." 

Says Dr. Weir, of St. Luke's Hospital : 

" In hospital practice, and where in private practice I can myself 
apply plaster, I do it ; but to my students I point out that Buck's 
apparatus is a much safer method for them to use, and generally for 
practitioners whose opportunities for acquiring large experience are 
few: because I find that unless carefully applied and watched, by fre- 
quent reopening, etc., curvature and shortening will sometimes occur 
unperceived, which cannot be the case in Buck's apparatus." 

The late Dr. Paul F. Eve, Professor of Surgery in the Nashville 
Medical College, employed the plaster of Paris, but not as an immovable 
form of dressing. Extension and counter-extension are made as in 
Buck's apparatus, and the limb is exposed to view daily and sponged. 
In order that these necessary examinations may be made, the plaster is 
applied according to the Bavarian method, so that it may be spread open 
without breaking the splint. 

The practice of treating fractures of the thigh, as well as all other 
fractures of the long bones, with the roller alone, and without either 
lateral splints or extending apparatus, first suggested by Radley, has 
found in this country but one distinguished advocate, the late Dr. Dud- 
lev, of Lexington, Ky. 1 Nor, with all my respect for that truly great 
surgeon, can I persuade myself that the practice is able to accomplish in 
any degree the indications proposed, nor indeed that it is, at least in the 
hands of inexperienced surgeons, wholly safe. Dr. D. of Aberdeen, 
Mi—., has reported to me one example in which, after the application of 
this bandage by ;i pupil of Dr. Dudley's, to a negro slave, who had a 
fracture of the femur, death of the limb ensued, and amputation became 
necessary. The negro was sixteen years old, and healthy; the fracture 
was caused by the fall of a tree or ;t branch, and was simple. The 
bandage was applied from the toes upwards to the groin, and was not 
opened for several days, at which time the whole limb was found to be 
in ;i state of dry gangrene, with the exception of the upper two-thirds of 
the thigh, which was swollen enormously, and partially gangrenous ;is 
high up as the groin. 

1 Amor. Journ. of the lied. Sri., vol. xix. p. 270; Transylvania Journal, April, 
1836; Boston " :!r g. Journ., vol. xxxiv. ]». 85. 



48G FRACTURES OF THE FEMUR. 

Dr. D. says : kk Having heard the history of the case carefully stated, 
observing the leg and the. lower part of the thigh to he in a state of dry 
gangrene, and seeing the marks of the bandage visibly impressed on the 
surface, my opinion was made up at the time that the gangrene had 
resulted from pressure of the bandage. The femoral artery at the groin 
■was in a sound and natural state, and if I mistake not, after the limb 
was removed, it was traced to the point of obliteration where the gan- 
grene commenced, and where the impression of the bandage was observed; 
thus far, I think, it was of natural size and calibre. Hence the conclu- 
sion is inevitable, 'that the death of the limb resulted from the pressure 
of the bandage, and not of one of the fragments. 

" It was a curious specimen of dry mortification, and I regret that I 
did not use the means of preserving it. I was then engaged in a very 
laborious practice, thirty miles from home, on horseback, and conse- 
quently could not conveniently spare the time to attend to it as an object 
of surgical curiosity. Dr. H. and myself cut into the leg in various 
places, in order to examine the muscles, arteries, nerves, etc., but found 
the integuments so hard that it was really difficult to penetrate them 
with a knife ; the resistance to the knife was more like that of dry hickory 
wood than anything else." 1 

It would seem almost superfluous to defend the use of side or coapta- 
tion splints in the treatment of fractures of the shaft of the femur. It 
will be remembered, however, that Radley, of England, and Dudley, of 
Kentucky, treated these fractures without side splints and without exten- 
sion. In 1844 I found Jobert, at l'Hopital St. Louis, employing only 
extension without side splints. SAvinburn, of Albany, rejects side splints 
in all fractures of long bones, relying solely upon extension ; and recently, 
I have been informed, Kronline, of Zurich, has recommended in the 
treatment of fractures of the thigh extension with the weight and pulley, 
without side splints. 

I do not think that either of these gentlemen have ever made many 
converts to their peculiar views, yet it may be well to give to the subject 
a brief consideration. 

Against side splints, considered independently of the means by which 
they must necessarily be maintained in position, there can be no possible 
objection. It is only the constriction, and obstruction to the free circu- 
lation caused by the bandages which bind them to the limb, to which any 
objection can be made. The same objection would hold against a roller 
applied directly to the skin, which by Dudley was substituted for the 
splints, but in a much greater degree, inasmuch as it is less easily re- 
moved or loosened in case the swelling increases the bulk of the limb. 
This I have always considered a valid objection to the roller applied 
immediately to the skin in this or in any other fracture, and as one of 
the reasons why the plaster-of-Paris dressings or any other form of im- 
movable dressing is relatively unsafe. In a degree, also, this objection 
] i olds against the continuous roller as a means of holding the splints in 
place. 

1 F<>r a more complete account of this interesting case, see Buffalo Med. Journ., 
vol. xiv. }). 193, Sept. 1858. 



FEACTUKES OF THE SHAFT OF THE FEMUR. 487 

If side splints are light, properly adapted to the limb, with no rough 
or unequal bearings : if they are not bound too tightly to the limb ; if 
they can be loosened or removed without disturbing the limb and are 
not continued beyond the period of their usefulness, they can do no 
harm, while they give important aid in preventing motion at the seat of 
fracture and in maintaining the fragments in line. This is especially 
true in fractures occurring through the middle portions of the shaft of 
the femur. If absolute quiet to the limb could be insured during the 
period of union, while asleep and while awake, if the patient had never 
occasion to move his head, shoulders, or nates, the protection usually 
afforded by side splints would be less needed ; but even then the conical 
shaped limb would find a very unequal and inadequate support upon the 
straight surface of the mattress. 

In short, in my opinion, the omission to employ side splints in most 
simple fractures of the shaft of the femur would greatly increase the 
danger of non-union and of deformity, and would therefore be inex- 
cusable. 

The treatment of these and other fractures by plaster of Paris, paste, 
starch, or dextrine has been already considered when speaking of the 
treatment of fractures in general. Thus far my experience will not war- 
rant me in recommending the immovable apparatus, as a general plan of 
treatment in fractures of the thigh. 

In the fourth edition I spoke somewhat more favorably of the results 
of this practice as declared by some of the house surgeons of Bellevue; 
still more lately one of the visiting surgeons has published some statistics 
which indicate a better average result than has been hitherto obtained 
by <»ther methods; but having since learned that these statements were 
not based altogether upon measurements made by these well-known and 
able writers themselves, I am unwilling to accept of them as trustworthy 
testimony. 1 For a review of Dr. Van Wagenen's report of cases treated 
by the plaster of Paris in Bellevue Hospital, the reader is referred to the 
chapter on General Prognosis. 

In order to assure myself as to whether we were able to make longer 
ami straighter thighs by the use of the plaster of Paris than by the 
method of extension as employed by myself and others, my later expe- 
rience has been carefully collated, but not selected ; every case in which 
the opportunity was afforded being recorded, and the results being con- 
firmed by my own testimony and the testimony of others. The facts 
thus obtained constituted the basis of an article written by me for the 
New York Medical Journal, and published in the August number for 
l x 74: but the great interest taken in the discussion of the merits of 
Mathiesson's plaster-of-Paris dressings, both in this country and abroad, 
during tin- last few years, seemed to me to call for a statement of expe- 

1 Prof. II. 1',. Sands, X. V. Med. Journ., June, 1871 ; Dr. J. D. Bryant, N. V. Med. 
Record, Sept. 15, 1-71: Dr. 8. If. St. John*, Amer. Journ. Med, Sci., July, 1*72. 
Reply to Dr. St. Johns, by the author, Bosp. Gaz.,etc., May 30, 1878; Dr. Si. Johns's 
reply, Louisville Med. News, S<-)>t. 28. 1878: Lecture on Fractures of the Femur in 
the Adult. Bellevue Hosp., by the author, Med. Record, Dec. 1. 1877; Dr. St. Johns, 
on tlr demy of Med . X. V.. May 11. 1878, Med. Record, July 20. 



488 FRACTURES OF THE FEMUR. 

rience which should cover a large number of cases, although it could not 
be expected in a treatise like this to give all the cases in detail, as was 
done in the journal communication already referred to. Of the cases 
neat ci I by plaster of Paris, and recorded in the accompanying tables, a 
majority were from the hands of other surgeons, and all were hospital 
cases: in almost every instance the surgeon treating the case having had 
a large experience in the use of plaster. With very few exceptions, the 
plaster was applied while the patient was under the influence of ether. 
After the plaster was applied most of the patients walked about with 
crutches ; but there were pretty frequent examples in which, for one rea- 
son or another, this was found impracticable, and the patients remained 
in bed. 

The amount of shortening has six times exceeded one inch. A con- 
siderable bend at the seat of fracture has occurred six times ; anchylosis 
of the knee, requiring surgical interference, has occurred six times, and 
in almost all cases it has been more troublesome than it is usually found 
to be after other plans of treatment ; once gangrene, amputation, and 
death followed, and once abscesses of the leg, paralysis, etc. 

The cases reported as treated without plaster were all treated by my- 
self. The method adopted being in the case of adults essentially that 
which is known as Buck's extension, but which I have, as will hereafter 
be seen, considerably modified. In the case of children, the method has 
been uniformly that v>hich I shall hereafter describe in its proper place 
as the method preferred by me in these cases ; permanent extension, such 
as is used in Buck's apparatus, being very seldom employed. Not one 
of these limbs has presented an excessive shortening — one inch being 
the maximum. Not one is bent at the point of fracture. None of the 
patients had bedsores, or troublesome anchylosis at the knee-joint. In 
one there was delayed union. Case 23 has been measured by many of 
the gentlemen connected with Bellevue, and all agree that the broken 
limb is longer than the other, yet it united promptly, and he walks with- 
out a halt. We have been unable, thus far, to find any other explanation 
of the increased length except the now well-established fact that the nor- 
mal lengths of thighs and of other long bones are pretty often unequal, 
and that probably this limb was originally longer than the other. The 
experiments of Reid 1 and of others have conclusively shown, I think, 
that it is impossible, unless at least fifty or one hundred pounds were 
on i ployed in the extension, to stretch the muscles beyond their normal 
length. If a limb after fracture and bony union is found longer than its 
fellow, no doubt it was longer before the fracture. We cannot, therefore, 
appreciate the objection made by Dr. Sayre to permanent extension by a 
weighi and pnlley, that it endangers a total separation of the fragments, 
and consequent non-union. Five children and one adult had perfect 
limbs; or, if we are permitted to include the case in which the limb is 
lengthened, two adults have recovered with perfect limbs. 

1 Reid, W. W., Buff. Med. and Surg. Journ., vol. vii. p. 134, Aug. 1851. 



FRACTUEES OF THE SHAFT OF THE FEMUR. 



489 



Cases treated with Plaster of Paris, Continuous Poller, Mathiesson's Met/tod. 



No. 


Age. 


Character of 
fracture. 


Point of 
fracture. 


Hospital. 


Am't of 
short'g. 


Deformity. 


Remarks. 


1 

2 


Yrs 
11 

15 


Simple. 


Middle. 


Bellevue. 
St. Francis. 


Inches. 

4 


f Slightly 

\ bent," 


J Anchylosis of 
\ knee. 


3 


16 


« 


« 


Park. 


ll 




f Anchylosis 


4 


17 




t« 


99th St. 


1 


Much bent 


-j broken up 


5 


»{ 


With frac 

of legs. 


Below \ 
trocb. J 


Park. 


1 


.. .« 


( under ether. 


6 


16 


Simple. 


" 


Bellevue. 


4 






t 


7 


" 


Middle. 


" 


1 






8 


39 


" 


" 


" 


1 






9 


37 


" 


" 


" 


1 






10 


63 


" 


Extracap. 


" 


* 






11 


26 


" 


Middle. 


Park. 


3 






12 


24 


» 


" 


" 


ll 






13 


25 


" 


" 


•' 


1 






14 


36 
21 
26 


» 


« 


Bellevue. 


n 

3 
8 




Anchylosis. 


15 






16 






17 


29 


" 


" 


" 


f 






18 


24 


(i 


<( 


(< 






Delayed union. 


19 


39 


« 


(i 


99th St. 


If 




20 


70 


u 


«< 


Bellevue. 






No union. 


21 


44 


Compound. 


" 




2 


Bent. 




22 


66 


Simple. 


" 


" 


1 


Much bent. 


Anchylosis. 


23 


50 


« 


" 


(; 


1 


Bent. 




24 


22 
33 


u 


Extracap. 


" 


3 
4 




Anchylosis. 


2-3 






26 

27 


23 
27 


" 


J Below 
\ troch 


" 


Perfect. 
H 




f Paralysis, ab- 


28 


46 


« 


r Above 
\ cond. 


Park. 


1 




\ scess, etc. 


20 


51 


Compound. 


" 


Bellevue. 


l 




f Gangrene, 
\ amp., death. 


30 


23 


Simple. 


Middle. 


99th St. 











It will be seen that the first table includes two cases in which serious 
results ensued. In Case 30 gangrene supervened on the third day after 
the accident, and on the second, after the dressings were applied ; ampu- 
tation was made, and the patient died. In Case 27 the plaster was ap- 
plied on the fifth day after the accident (November 13, 1873), and 
removed twenty days later, when the patient found he had no sensation 
in the limb below the knee; the leg was also much swollen below the 
knee. Subsequently abscesses formed in the leg, large sloughs occurred, 
and the calcaneum became carious. 

Both of the preceding cases are reported at more length in the num- 
ber of the Neiv York Medical Journal for August, 1874. 



4D0 



FRACTUKES OF THE FEMUR. 



i eated by myself, by my own and Buck's Methods. 



No. 


A.ge. 


Character of 
fracture. 


Point of 
fraoture. 


Hospital. 


Amount of Deform> • Rema ' rka . 

shortening. J | 




Yr>. 








Inches. 


1 


2 


Simple. 


Middle. 


Bellevue. 


1 


Straight. 




2 


6 


» 


" 


» 


Perfect. 






3 


4 


« 


" 


Private. 


i 






4 


6 




" 


•■ 


Perfect. 






•■» 


10 


» 


" 


Bellevue. 


<< 






6 


9 


" 


" 


" 


■1 






i 


15 




« 


" 


1 






- 


5 


Compound. 




" 


Perfect. 






9 


18 


Simple. 


" 


" 


" 






10 


33 


" 


" 


" 


3 
f 






11 


20 


*« 


" 


" 


3 






12 


•->() 


; < 






f 






13 


35 


" 




Long Is. C. 


f 






14 


60 


" 


Intracap. 


Park. 






15 


50 


" 


Extracap. 


" 


l 6 




16 


40 


" 


" 


Bellevue. 


I 






17 


i0 


" 


" 


" 


1 






18 


35 


" 


" 


» 


7s 






19 


40 


" 


«• 


" 


1 






20 


60 


" 


'< 


Long Is. C. 


1 




Toes everted. 


21 


45 


" 




Private. 


1 




" " 


22 


70 




Neck. 


" 


1 




u (< 


23 


40 


" 


Above knee. 


Bellevue. 


Lengthened. " 


24 


22 


11 


Middle. 


" 




' ; De.laved union. 








" 



These two constitute the only examples of serious accidents which 
might possibly have been due to the mode of dressing, in the table of 30 
cases, which, as lias already been explained, were recorded without selec- 
tion ; but they are not all which have come under the writer's notice. 
In one case at Bellevue an enormous perineal slough was caused by the 
pressure of the plaster. In addition, also, to the case of gangrene and 
death included in the first of the preceding tables, the following have to 
be recorded : 

Lizzie Gibbons, vet. 24, fell upon the sidewalk and broke her thigh 
about six inches above the knee-joint. She was carried to Bellevue 
Hospital, and on the same day, under the influence of ether, and with 
limb extended by pulleys, plaster dressings were applied. Twenty-four 
hours later the toes looked dark, and the splint was opened about the 
foot. On the following morning the house surgeon found the limb cold, 
and sensation greatly impaired. The dressings were at once opened 
freely. Death took place on the third day. 

Charles Grim, set. 62, admitted to Bellevue Jan. 2, 1871, with a 
fracture of the cervix femoris, which had just occurred from a fall on 
the ice. On the fourth day plaster of Paris was applied with the aid of 
ether and pulleys. Two days later the record reads: "Patient has a 
large sore on sacrum, extending almost to the loins ; splint taken off; 
unities cold and blue: pulse felt with difficulty; suffering from some 



FRACTURES OF THE SHAFT OF THE FEMUR. 491 

dyspnoea : lungs emphysematous, and old fracture (?) somewhere ; this 
P. M. he died.'' 1 

The two following cases deserve to be mentioned in this connection, 
inasmuch as the class of casualties to which they belong are chiefly inci- 
dental to the plaster-of-Paris method. In no other form of dressing have 
anaesthetics been employed so universally. 

John Stockander was admitted to Bellevue August 2, 1872, with a 
fracture of the left femur below the trochanter. Buck's extension was 
applied at first, and on the eighteenth day the patient was placed under 
the influence of ether, the pulleys attached, and the application of the 
plaster commenced. The breathing was soon observed to be gasping. 
Ether was withheld a few minutes, when, as the breathing became 
regular, it was resumed. Soon after the pupils rapidly dilated, the 
breathing ceased, and in a few minutes more, in spite of every effort to 
resuscitate him, death supervened. There is every evidence to sustain 
the opinion that the ether was given carefully and in the usual manner. 2 

In the case of Mary Shules, No. 11 of the second table, ether was 
administered for the purpose of applying plaster ; and while extension 
with pulleys was employed, and the bandages were being applied, " she 
suddenly ceased to breathe, and her face became purple." By prompt 
resort to various expedients, including Marshal Hall's method, Sylves- 
ter '< method, and electricity, she was rescued. " Dr. Figaro thinks her 
respiration was completely suspended two or three minutes." 3 The 
attempt to apply plaster was then abandoned, and Buck's extension sub- 
stituted, with the result of giving her a limb shortened only three-eighths 
of an inch. 

I shall hereafter mention another case of gangrene caused by the 
plaster dressing, in connection with fractures of the femur in children. 

Billroth has noticed the greater frequency of non-union under the 
plaster-of-Paris treatment ; and my own attention has been called re- 
peatedly to these cases. 

T. B., a laboring man, set. 60, fell Oct. 25, 1875, breaking his right 
femur near its middle. On the following day, with pulleys, the leg was 
extended until it was said to be as long as the other, and then the 
plaster-of-Paris splint applied. He left his bed, and was allowed to go 
about on crutches at the end of one week, as recommended by the 
advocates of this method. The apparatus was removed at the end of six 
week-, when the limb was crooked, and, as the mnn thought, not united. 
The surgeon did not, however, recognize the failure to unite until some 
time later. 

This man consulted me about seven months after the accident. I 
found only fibrous union of the fragments, the limb being bowed out at 
the point of fracture, and perfectly useless. 

1 A Comparison of the Results of Treatment of 308 Cases of Fracture oft lie Femur, 
: : ';i!. by Frederick E. Hyde, .M.J)., New Fork. New York Med. 
Journ.. October, 1874, j 

* Death from Ether, by W. I>. Dunning, .M.I).. Acting House Surgeon, Bellevue 
Hospital. New York Med. Rec., October 1. 1872. 

'■' New York Med Journ., August, 1*74, p. 134. 



492 FRACTURES OF THE FEMUR. 

In July, 1875, Dr. Glass, House Surgeon, called my attention to a 
similar case which had been treated in Bellevue Hospital. 

A danger in the use of plaster of Paris as a dressing for compound 
fracture of the femur lias not hitherto been mentioned, namely, that in 
case of a secondary haemorrhage from the femoral artery, it would be 
impossible to compress the artery over the pubes, in Scarpa's space, or 
at any other suitable point, and the patient might die before succor 
could be given. In cases of compound fracture of the femur, from gun- 
shot injuries, such secondary haemorrhages are not very uncommon ; and 
such a haemorrhage has occurred when the femur has been broken very 
obliquely, and thrust through the flesh, and has in its course so contused 
the femoral artery, or has passed so near to it as to have caused a subse- 
quent sloughing of the artery. 

I do not see how one is to provide for such a possible accident ; since 
a fenestra opposite the wound would not give space sufficient to secure 
the bleeding vessel ; and a sufficient fenestra over the groin might so 
much weaken the splint as to render it of little or no value. The acci- 
dent has occurred, and may occur again ; the surgeon ought, therefore, 
in case he uses the plaster after a compound fracture, so far as possible, 
to provide an opening sufficient for a free approach to the upper portion 
of the femoral artery, in order that pressure could be applied and the 
bleeding controlled until the vessel was secured. 

In no other limb than the thigh is this danger so imminent, for the 
reason that nowhere else are the vessels which are liable to rupture so 
large. 

It has been almost the constant practice of late, in this country, to 
employ ether and the pulleys while applying the plaster, and this is 
considered one of the great essentials to success. It is proper, then, to 
put into the account, as against this method, the danger from anaes- 
thetics ; and to inquire, perhaps, whether the usual danger attending the 
exhibition of these agents is not increased by the condition of forced 
decubitus, and of extension to which the patients are subjected while the 
plaster is being applied. 

A case reported to the South Carolina State Medical Association, in 
1874, by Dr. Robert W. Gibbes, of Columbia, S. C, furnishes the first 
opportunity yet presented to me to observe in the autopsy the result of 
treatment in a case in which plaster of Paris has been employed accord- 
ing to the method just described. Dr. Gibbes has been kind enough to 
send me the specimen, and also photographs, from which the accompany- 
ing woodcuts were made. 

Mr. J. II. W., 33t. 83, weighing 165 pounds, enjoying robust health, 
fell eighteen feet, January 2, 1873, striking, as he thinks, upon the 
right hi]). Dr. (iibbes was called and detected a fracture of the right 
femur just below the trochanters. Fifteen hours after the accident, 
I)]-. Gribbes, assisted by other surgeons, applied "the plaster-of-Paris 
dressing after the well-known method in vogue for several years past in 
Bellevue Hospital, my venerable patient being kept for some time sus- 
pended above the table and fully under chloroform." 

On the fourth day he made an attempt to walk, but the attempt was 
not resumed until about the eighteenth day, after which "he began to 



FRACTURES OF THE SHAFT OF THE FEMUR. 493 

walk around his room daily." The apparatus was removed on the forty- 
third day. The union was firm, and the limb appeared to be shortened 
three-quarters of an inch, as determined by several careful measure- 
ments. On the 29th of June, about six months after the accident, he 
died of apoplexy. At the autopsy it was found that the femur was 
broken just below the trochanters into three fragments. 

Fig. 184. Fig. 185. 






Dr. Gibbes's case. 

Posterior view. Anterior view. 

A, B, C, three fragments ; d, bony bridge. 

The result of the treatment, considering his age and weight, was all 
that could have been expected; and the preference given to the plaster 
in this particular case was judicious; but the point to which I desire to 
direct the attention of the reader is, that the specimen does not sustain 
the claim made by certain advocates of this method, that it is able to 
prevent a shortening in all cases. In this case there is, according to the 
measurements made before death, a shortening of three-quarters of an 
inch. An examination of the specimen convinces me that it is some- 
what more ; but however this may be, one thing is certain, the limb 
shortened to the same degree that it would have done if no apparatus 
whatever had been employed. It shortened until the upper end of the 
lower fragment struck and was arrested by the neck. The apparatus 
enabled the patient to walk sooner than he could otherwise have done; 
and this i> a consideration of more importance often in an old man than 
the length or form of the limb, and I doubt whether any other plan 
would have made the limb in this case any longer. 

Dr. John T. Hodgen, of St. Louis, in a paper on the "Value of Ex- 
tension in the Treatment of Fractures of the Femur," and especially as 
effected by his mode of suspension, speaks of the attempt to accomplish 
this by a plaster-of-Paris splint, as a proposition too absurd to deserve 



494 FRACTURES OF THE FEMUR. 

serious consideration; and in justification of this statement he has given 
several unanswerable anatomical and surgical facts. 1 

It will be necessary to describe a little more in detail than has been 
done in the chapter devoted to the general consideration of fractures, 
the method of applying the plaster of Paris in fractures of the thigh, 
which was formerly adopted at Bellevue. I say u formerly," because I 
have not seen it employed in any recent case at Bellevue during the 
last two years. Certainly if it has been employed, the practice is very 
exceptional. 

A plaster-of-Paris bandage is applied to the foot and leg some hours 
before the complete dressing is made. It is better that this should be 
done twelve or twenty-four hours before, in order that this portion of 
the apparatus may become solid, and not remain liable to be indented, 
or pressed inwards toward the limb when extension is applied, and also 
in order that the surgeon may know by an examination of the toes after 
the lapse of a sufficient time that the dressing is not too tight. 

This section of the apparatus should extend from a little above the 
metatarso-phalangeal articulation of the toes to about the junction of the 
middle and lower thirds of the leg. Instead of the soft woollen cloth, 
which is generally to be preferred in the upper part of the limb, we 
may here lay next to the skin a sheet of cotton-batting, and this should 
be thicker over the instep and above the heel than elsewhere. We can- 
not take too many precautions in protecting the limb about the ankle 
from undue pressure. It will be remembered, also, that while at the 
ankle the splint should be thick, composed of five or six consecutive 
turns of the roller, it may be light upon the foot, and near the upper 
end of the splint upon the leg. 

While the dressings are being applied, and until they have hardened, 
the foot must be held carefully at a right angle with the leg, and in a 
proper line as to inversion or eversion ; but the assistant must take care 
that he does not, with his hand or fingers, indent the plaster. 

A temporary congestion of the toes almost always ensues upon the 
application of the bandage, but this usually subsides within twenty-four 
hours. If it does not, the bandage is too tight, and must be cut open. 

In applying the final dressings on the following day, or when the first 
dressing has become solid, the patient is laid upon a bed composed of 
two or three mattresses, or of a sufficient number of folded blankets, his 
loins, shoulders, and head resting upon the bed thus constructed, while 
his hips, thighs, and legs extend beyond the bed. In order to support 
the lower portion of the body in this position a piece of a cotton roller, 
three inches wide and two yards long, having been lubricated with sweet 
oil, is passed under the pelvis, and tied above to a bar supported by a 
stanchion, as seen in the woodcut (Fig. 186). Various methods of sup- 
porting the pelvis have been devised, but this is the most simple and 
efficacious. The piece of bandage is directed to be softened with oil, in 
order that it may be easily withdrawn when the dressing is hard; but if 
it has not formed a cord this may not be necessary, and it is sometimes 
cut off and left inclosed with the splint. 

Hodgen, St. Louis Med. und Surg'. Journ., April, 1878. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



495 



The iron stanchion, wrapped with woollen cloth, is now brought against 
the perineum, and the pulleys made fast to the foot by a noose of cotton 
bandage. Moderate extension is made, sufficient to support and steady 
the limb, but not sufficient to overcome the shortening. 



Fig. 186. 




Extension during application of plaster of Paris. 

The surgeon now wraps the limb, including the pelvis, thigh, and leg, 
down to the first splint, with soft but coarse woollen cloth, cutting out 



Fig. 18 




Extension continued until the plaster i.< hard 



portions here and there, and fitting it smoothly to all the irregularities 
of surface, and stitching it loosely, when it is in place, over the region of 
the tuberosity of the ischium and perineum. Where the splint is liable 



496 FRACTURES OF THE FEMUR. 

to make undue pressure, two or three thicknesses of cloth may be placed, 
or cotton-batting may be used instead. 

Everything being ready, the assistant places the patient completely 
under the influence of an anesthetic, and then extension is made with 
the pulleys until the limb is restored, if possible, to the same length as 
the other. 

The bandages, filled with dry plaster, and previously soaked a few 
minutes in water, are then applied from below upwards, including, finally, 
the pelvis as high as the loins. At no point must they be drawn tightly, 
but only wdth sufficient firmness to insure their accurate adaptation to 
the limb. Three, four, or five thicknesses are required, according to the 
size of the limb, or the age of the patient. In front of the groin, where 
the splint is most liable to become broken when the patient gets up, there 
should be laid two or" three strips of binder's board, or narrow metal 
strips, tin or zinc. 

After each successive layer is applied, the surgeon will sprinkle a 
little dry powder upon the surface, and smooth it over with his hand 
previously dipped in water. As soon as the plaster is hard, usually 
within twenty or thirty minutes, the suspending apparatus is removed, 
and the patient placed in bed. 

Those surgeons who omit to include the foot and ankle in the plaster 
splint do not, I think, avail themselves of the most important and most 
reliable means of making the little extension that can be made perma- 
nently in this form of dressing. When the limb shrinks, the condyles of 
the femur and the calf of the leg offer very imperfect or no resistance to 
the action of the muscles of the thigh, and extension is completely lost. 
Let it be understood, also, that the author does not recommend that the 
perineum shall be made the point of counter-extension ; and in this he 
is sustained by the majority of those who have used this dressing; and 
the shrinkage of the muscles of the thigh, which soon ensues, renders it 
equally impossible, ordinarily, to maintain permanently, against the only 
slightly conical surface of the upper portion of the thigh, any effective 
counter-extension. I think, with Dr. Hodgen, that the proposition is ab- 
surd, and I do not see how any really practical surgeon can entertain it. 

The patient can, in most cases, leave his bed by the third or fourth 
day after the splint is applied. If he keeps out of bed the limb will not 
shrink as much, and the necessity for readjustment will less often arise. 
But he cannot remain in the erect position all the time, and at the best 
there will be, as experience shows, opportunity enough for the limb to 
shrink, and for the apparatus to become loose. In case it becomes loose 
it cannot be refitted by cutting out a portion and folding the splint in 
again, since it is too inflexible, and will not be made to bear upon the 
same points as before. At Bellevue, when a plaster dressing becomes 
loose it is always removed and a new one applied in the same manner as 
at first. 

Finally, having considered somewhat at length the leading plans of 
treatment which have, from time to time, been suggested and employed 
by our best surgeons both at home and abroad, I desire to describe in 
greater detail those methods and forms of apparatus which my own 
experience has taught me to prefer. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



497 



As to posture, my opinions are in accord with the opinions of a vast 
majority of the most experienced surgeons of the present day. The 
straight position will, on the average, give the best results. Careful 
measurements made by myself in several hundreds of cases, a portion 
of which have been published in my statistical tables, 1 have demonstrated 
that the average shortening of the limb is greater after any method of 
treatment in which the flexed position is employed, than after treatment 
with extension in the straight position. Whether this statement ought to 
include broken femurs treated by Dr. Hodgen's method I cannot say, 
since I have not measured many limbs treated by his method, and he 



Fig. 188. 



Fig. 189. 





Badly united fracture of the femur: treated 
without permanent extension. 



Fracture of femur just below trochanter 
minor. 



has not given to the profession any exact statistical record of his own 
results. I must, however, state my conviction that the average results 
of these cases will fall a good deal short of the average results obtained, 
when proper extension is employed, in the straight position. These 
same carefully recorded observations, and my later observations, have 
also shown that the flexed position, contrary to the reiterated statements 
of most of its advocate-, is more apt to entail angular deformity. Fig. 
188 is a fair illustration of what I have seen occur more than once when 



1 Fracture Tables, by F. H. Hamilton, 1853. 
32 



498 FRACTURES OF THE FEMUR. 

the flexed position 1ms been adopted; a condition which is impossible 
when proper extension is employed in the straight position. 

There are a few who, rejecting the flexed position in fractures of the 
middle of the shaft, still declare for this position a preference when the 
fracture occurs just below the trochanters, and in the case of fractures 
at the base of the condyles. 

According to Malgaigne, who has devoted especial study to this sub- 
ject, there is no satisfactory evidence in favor of the flexed position when 
the fracture occurs below the trochanters. It is not directly forwards, 
but forwards and outwards, that the lower end of the upper fragment is 
carried by the action of the psoas magnus and iliacus internus; so that in 
order to meet the supposed indication it would be necessary to carry the 
lower part of the limb outwards also, a position which would certainly 
be found inconvenient, if not actually impracticable, in the majority of 
cases. Nor can the tendency of the upper fragment to advance in the 
forward direction, and consequently to separate from the low T er, be met 
effectually by posture alone, unless the thigh is completely flexed upon 
the body. Indeed, it is apparent that the position of moderate flexion 
will rather favor the action of those muscles which are supposed to be 
chiefly responsible for the displacement. When the thigh is extended 
upon the body, the psoas magnus and iliacus internus are acting in the 
direction of, and nearly parallel to, the axis of the femur, and conse- 
quently to a disadvantage : but when the limb is lifted, their action is more 
nearly at a right angle with the shaft, and their ability to displace the frag- 
ment is greatly increased. 

Moreover, it ought to be understood that broken bones are seldom or 
never displaced or separated, in the same manner they would be if they 
were not surrounded with many other structures which have suffered little 
or no disruption : they pass each other, but do not separate widely, being 
held together by shreds of periosteum, muscles, tendons, ligaments, etc. 
The same happens when this bone is broken just below the trochanters ; 
the upper fragment lies always, or almost always, in immediate contact 
with the lower, and whatever force is brought to bear upon the lower 
fragment more or less directly influences the upper ; we can then by 
extension applied to the leg, draw down not only the lower fragment, 
but we can drag into line the upper fragment. No doubt in this attempt 
we >hall meet with some resistance from the muscles above named; but 
experience has always shown that even moderate extension, applied 
steadily and without interruption, seldom or never foils to overcome, in 
a great measure, the resistance of the most powerful muscles. We con- 
stantly avail ourselves of this principle in overcoming the abnormal con- 
traction of muscles in connection with diseased joints, in the reduction 
of old dislocations, and in many other ways. 

Whatever the advocate- of flexion in fractures of the femur may say 
to the contrary, they are never able in this position to employ effective 
extension and counter-extension. A careful examination of all the 
double-inclined planes which have been devised, including Nathan R. 
Smith's and Dr. Hodgen's suspending apparatus — I say it with all 
respect for these distinguished surgeons — it appears to me, ought to 
convince any experienced observer that such is the fact. Whatever 



FRACTURES OF THE SHAFT OF THE FEMUR. 499 

other excellences they may possess, this does not belong to them. But 
extension is, of all the indications of treatment, that which is of the 
greatest importance in nearly all fractures of the thigh, and no less 
important in the upper third than in the lower. Indeed, it is of more 
importance in case of a fracture through the upper than in the case of a 
fracture through the lower third, since, as my measurements have shown, 
the higher the point of fracture the greater is the tendency to shorten, 
in consequence of the action of those powerful muscles which, arising 
above, have their insertions into the lower fragment. 

In the case of all those double-inclined planes where the body rests 
upon a bed. there can be no counter-extension except the weight of the 
pelvis and its contents. It will not do to fasten the pelvis to the bed by 
hands, as every one who chose to make the experiment would soon learn; 
nor will the groin tolerate the pressure of counter-extending splints or 
bands. These things have been tried in a thousand ways, and aban- 
doned. The weight of the pelvis alone, not of the entire body, is the 
only counter-extending force which can be made available in these forms 
of apparatus, and this is wholly insufficient. In Nathan R. Smith's 
anterior suspension splint, not even the weight of the pelvis is employed 
as a means of counter-extension, the pelvis being secured to the splint 
by rollers, equally with the thigh and leg, and there is no possible chance 
for extension and counter-extension. 

After all, I prefer to leave this question to the verdict of experience, 
and happily this seems to be conclusive, if we may accept the almost 
unanimous testimony of those surgeons who have enjoyed the largest 
hospital practice. In my own experience the ordinary double-inclined 
planes have constantly given the worst results, both in regard to length 
and lateral displacement ; they are the most difficult to manage, and are 
the most fatiguing to the patients. Nathan R. Smith's suspending ap- 
paratus permits the limb to shorten indefinitely ; and it affords inade- 
quate support along the centre of the shaft, in consequence of which the 
limb is apt to unite with a backward curvature or angle. In some gun- 
shot fractures treated by this apparatus this posterior curve or angle has 
been excessive. 

Even the old methods of extension were preferable to flexion ; but 
they had always two serious drawbacks. First, in the excoriations and 
ulcerations incident to the application of extending bands or gaiters, or 
whatever else was employed for this purpose. Again and again I have 
seen ulceration of the instep, of the integuments above the heel, and of 
other parts of the foot and ankle, from extending bands. And. second. 
from similar excoriations, ulceration.-, and deep sloughs about the groin 
and perineum, caused by the counter-extending hand. It is true these 
accidents did not occur often, and sometimes they were due wholly to 
negligence; but. in order to avoid them, we were compelled to limit 
very much the amount of extension, and to exercise unceasing vigilance. 
At lj'-]]<-vue. ;) ^ I have elsewhere reported, an attempl was made to em- 
ploy counter-extension in the perineum of an adult, by plaster of Paris 
applied in the usual manner for a broken femur, and as ;i consequence 
a perinea] slough was soon formed two or three inches in depth by 
al inches in length. Lente, the Burges, myself, and others sought 



500 FRACTURES OF THE FEMUR. 

to overcome some of the difficulties of the perineal band by various con- 
trivances; and perhaps in some measure we were successful, but still 
the danger of ulceration existed wherever much force was employed, or 
the integuments were unusually delicate. Gilbert's plan of substituting 

adhesive plasters for the usual counter-extending band, in the perineum, 
and Buck's plan of employing elastic tubing, possess no real advantages. 
The truth is, there is no point about the groin, perineum, or pelvis upon 
which, by one surgeon or another, the pressure has not been made, and 
more or less distributed, for the purpose of counter-extension ; and there 
is no possible method, perhaps, which has not been employed; yet, after 
a fair trial, the results are the same. The pressure must be moderate, 
or serious accidents will occasionally happen. 1 

Hodge's attempt to make the counter-extension from the sides of the 
trunk by strips of adhesive plaster, as already described, is wholly ineffi- 
cient. They will loosen inevitably in a few hours. 

Our first great step of progress in the treatment of fractures of the 
thigh — first in importance, but not in order of discovery — consists, then, 
in having secured counter-extension by the weight of the body alone, 
and this is accomplished by simply elevating the foot of the bed from 
four to six inches. I have not used a perineal band, except in cases of 
children, for twenty years ; and, in case of children, the weight of the 
body is still my chief reliance. None of my colleagues at Bellevue use 
the perineal band to-day. 

The first to suggest and practise this was Dr. James L. Vaningen, of 
Schenectady, New York. (We shall see hereafter that Dugas attempted 
to make counter-extension by the weight of the body at a still earlier 
period, but he did not elevate the foot of the bed.) His method was 
reported to me, probably, in 1855, and was published in 1857, in con- 
nection with my Report on Deformities after Fractures, in the Transac- 
tions of the American Medical Association, accompanied with three 
woodcuts for the purpose of illustration. The foot of the bedstead was 
much more elevated than has been found necessary in later experience. 
It is interesting to note, however, as evidence, that Dr. Vaningen had 
practical experience with this method, that he directed especially that 
the pillow should be kept under the head only, " so as to keep the neck 
and shoulders quite free." 2 According to the statements of Dr. Robert 
F. Weir, of this city, Dr. Buck first elevated the foot of the bed for the 
purpose of making counter-extension, in 1859, while Dr. Weir was an 
interne of the New York City Hospital. 3 Dr. Buck first publicly 
described his method in a communication to the N. Y. Academy of 
Medicine, in 1861. 4 

The second step was the employment of the weight and pulley as a 
means of extension. I am indebted to Dr. Martin, of Boston, for the 
evidence that this method of making extension was known to Hildanus, 
in the 16th century, although it seems to have passed very much into 

1 For r;i-<- of Bloughing, etc . from perineal band, see N. Y. Journ. of Med., vol. 
xiv., I'll eer., i> 261, Starch, 1^">»'> : also same journal, Jan. 1840, p. 239. 

2 Vaningen, Trans. Am. Med. A— i.e., 1857, pp. 430-7. 

3 Mod. Record, March 9, 1878, p. 181. * Amer. Med. Times, March 30, 1861. 



FRACTURES OF THE SHAFT OF THE FEMUR. 501 

disuse until recently revived by American surgeons. 1 John Bell, in his 
Principles of Surgery, published at Edinburgh in 1801, speaking of a 
method described by Hildanus, says : fct But surgeons did at last fall upon 
a method which absolutely insured the permanent extension. For being 
wearied with this perpetual turning of screws to tighten the bands 
around the ankle, they at last most happily thought of putting a pulley 
to the foot of the bed and hanging a good jack-stone to the heel. 1 have 
(in next page) drawn the bed, the surcingle or horse-girth for the body, 
and the jack-stone of Hildanus for hanging to the heel, and, according to 
my poor conception, the method of permanent extension was by this 
rendered so perfect that Mr. Desault could do nothing but disgrace him- 
self by attempting any farther improvement." . . . " If this girth 
do not" "prevent the body from gravitating toward the fractured limb, 
if the jack-stone do not prevent the limb being detracted toward the 
body." •• there must be something in the theory and practice of Mr. 
Desault passing all comprehension."' 

In the above description we see a full recognition of the value of the 
pulley and weight, but the body was prevented from descending by being 
tied to the bed. and the extension was made by a garter. We need not 
be surprised, therefore, that the pulley and weight under these disadvan- 
tages were soon laid aside and forgotten. Guy de Chauliac, Suetin, 
and Nathan Smith, according to Malgaigne, 2 employed occasionally the 
pulley and weight. Boyer says the practice is very ancient. Dr. Wm. 
C. Daniell, of Savannah, Georgia, treated a case in this manner in 
1819, and again in 1824, the latter of which he published. The ordi- 
nary perineal band and a garter were used for counter-extension and 
extension. 3 In 1854, L. A. Dugas, of Savannah, Georgia, published an 
account of the method employed by himself, with an illustration. 4 This 
illustration, with a brief explanation of the mode of using the apparatus, 
was republished in my report to the American Medical Association in 
1857, pp. 434—5, and again in the first edition of this treatise published 
in 1 s »i'». Dr. Buck's communication to the Academy of Medicine con- 
tains no allusion to this plan of Dugas, but in his illustrations of his own 
method the small cannon-ball is used as a weight precisely as in Dugas's 
method. I do not mention this as an evidence of unfairness on the part 
of Dr. Buck, but only to indicate that lie had probably seen Dr. Dugas's 
woodcut. Dr. Buck had evidently intended to combine several improve- 
ment.-, for no one of which has he claimed the original conception. 

Dugas used ;i piece of bandage as his means of applying extension; 
but lio omitted the perineal band, which had not been done by Buck 
when he first made public his own method. Dugas relied upon the 
weight of the body To make counter-extension, saying that "the resist- 
ance of the patient's body will effect counter-extension :" ;i statement 
which Later experience has Bhown t<> be not correct, unless, as Brst 
amended by Vaningen, the foot of the bedstead is somewhal raised. 

The third great step of improvement, and thai which alone makes 
adequate extension, in most cases, possible, was the substitution of adhe- 

1 Martin, X. C. Med. Journ., Feb. 1878 ■ Malgaigne, op. 'it., p. 239. 

Daniell, Amer. Journ. Med. Sei., vol. iv. ]> 
4 Dugas, Southern Med. and Surg. Journ . Feb. is.",}, p. 69. 



502 FRACTURES OF THE FEMUR. 

sive strips, laid along the whole length of each side of the leg, in place 
of the gaiter. Of this, also, we are no longer permitted to speak as a 
novelty, the researches of Dr. Martin, already referred to, having brought 
to light the following paragraph in the works of Dr. Gooch : 

" To answer the same purpose, 1 have confined one end of a strong 
strip of sticking plaster, of a suitable length and breadth, under a circu- 
lar piece of the same, about the middle of the side of the foot, carrying 
it over the heel, up the leg, and confining the other end above the calf 
with another circular plaster, first, gradually bring down the muscul. 
gastrocnem. as far as they will readily yield; giving the limb, at the 
same time, the position described in my treatise on wounds. On the like 
occasion, I have also fixed one strap by the circular about the foot, and 
another by that above the calf of the leg, passing the one through a slit 
in the other, and using them as the uniting bandages ; but then two 
more circulars are requisite to confine the other ends of the longitudinal 
straps securely." 1 

This also, like extension by a pulley and weight, seems to have been 
forgotten until revived by some American surgeons. The first allusion 
I find to it in recent literature is by Dr. F. W. Sargent, of Philadelphia, 
in 1848, who says he derived the suggestion from Dr. E. Wallace, of 
Philadelphia, by whom they were used successfully while he was the 
Resident Surgeon of the Pennsylvania Hospital. Both of these gentle- 
men used long strips of adhesive plaster, of an inch or more in width, 
carrying them spirally down the leg from a point about midway between 
the foot and knee, after which they were, in some cases, made secure with 
rollers. 2 

In the third volume of the Transactions of the American Medical 
Association (1850) the same method is described as being recommended 
by Dr. Josiah Crosby, of New Hampshire, the only difference being that 
he carried the adhesive plaster as high as the knee. 3 In this brief notice 
of Dr. Crosby's plan, the editor remarks that Dr. Sargent had in his 
Minor Surgery described essentially the same, as being first practised 
by Dr. Wallace. Vaningen suggested the same in connection with the 
elevation of the foot of the bed, in 1857, as will be seen by reference to 
my reports, before referred to. Dr. Buck spoke of it publicly in his com- 
munication to the Academy of Medicine in 1861. 

Of the claims instituted for Dr. Mosely, of New Hampshire, who says 
his use of these strips dates back to 1840, and the like claims of Gross, 
Swift, Ennis, and others, we can only say they were unfortunate in not 
earlier giving their views and practice to the public. 

Finally, it is by the combination of these three essential principles 
with the short side-splints and one long side-splint, which shall reach 
from near the axilla to beyond the foot, to prevent the outward bowing 
of the thigh and to prevent e version of the leg, that the superiority of 

1 ;: Medical and Chirurgical Observations as an Appendix to a former Publication, 
by Benjamin Gooch, Surgeon, London, printed for G. Bobinson, in Pater Noster 
Bow, and K. Beatniffe, in Norwich." No date, but about 1771. N. C. Med. Journ., 
Jan. 1878. Martin. 

■ Minor Surgery, by V. W. Sargent, M.D., Lea & Blanchard, Philadelphia, 1848. 

■ Crosby, Trans. Am. Med. Asso., 1850, vol. iii. p. 383. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



503 



extension in the straight position can alone be demonstrated. The long 
outside splint, which 1 have myself added to the apparel, is only second 
in point of importance to either of the others, and that whether the frac- 
ture be in the neck or the shaft, in children or in adults. In children, 
however, it is supplied by the double splint. 

With regard to fracture beds, which, when surgeons adopted the flexed 
position in the treatment of fractures of the thigh, were often very use- 
ful and sometimes necessary, I must say that, in the treatment of these 
fractures in the extended position, they are not needed. We never use 
them for this purpose at Bellevue, nor do I think they are used at, any 
hospital in this city. If the bed is sufficiently long and the mattress is 
smooth, firm, and even, nothing more is required. Properly shaped bed- 
pans can always be used without disturbing the limb, and the arrange- 
ments for changing the position of the limb are not only useless, but 
such changes are actually injurious. Inasmuch, however, as in certain 
complicated cases of fracture of either the thigh, leg, or foot, adjustable 
or movable "invalid" beds may be needed, when extension is not to be 
attempted, I shall see fit to allude to a few of those which are best known 
among American surgeons. 

As invalid beds, the best known and most ingenious American con- 
trivances are those invented by Jenks, 1 Daniels, the Burges, Addinell 

Fig. 190. 




E. Daniels's invalid bed. 2 

Hewson, of Philadelphia, 3 J. Rhea Barton, B. II. Coates, of the same 
city. 4 and J. Crosby, of Manchester, N. H. 5 

In my earlier practice I have had constructed a simple frame, coveted 
with a stout canvas sacking, having a hole at a ^oint corresponding with 
the position of the Dates, and this I have laid directly upon a common 
four-post bedstead. A mattress and one or two quilts must be placed 

1 Jenks, GKbson'e Surgery; also the 5th ed. of this treatise, Pig. 185, p. 445. 

Pigs. 186 and L89 of 5th ed. 
■ Hewson, Amer. Journ. Med. Sci., .July, 1868, p. 101. 
* Eclectic Repertory, 6th and 9th vols. 

5 Crosby, T Military Surgery, by Frank II. Hamilton, 180.",, p. 413. 



504 



FRACTURES OF THE FEMUR. 



upon the boards of the bedstead underneath the sacking, and a sheet or 
two above the sacking, upon which last the patient is to be laid. In 
arranging the linen underneath the patient, the most convenient plan is, 



Fig. 191. 




Crosby's invalid bed, closed. 



instead of using only one sheet, which will require that a hole shall be 
made in it corresponding to the hole in the sacking, to employ two sheets, 
and. doubling them separately, to bring the folded margin of each from 



Fig. 192. 




Crosby's invalid bed, open. 
The bed is movable, and can be run out fioru under the patient and changed. It is then 
run back, the hooks B being made fast to the catches A. By turning a crank at C, the rail 
D is revolved, which winds up a strap passing over the pulley G, and the bed is raised to its 
position, thus taking off the weight of the patient from the bands by which he was tem- 
porarily suspended. 

above and from below to the centre of the opening. When the patient 
has occasion t<> use the bed-pan. it is only necessary that two or four 
person- should lift this frame, and place under each corner a block about 



FRACTURES OF THE SHAFT OF THE FEMUR. 



505 



Fig 193. 

■ 



I 



one foot in height, or it may be raised by a pulley and ropes suspended 
from the ceiling. 

My usual practice now. in a private house, is to remove the foot-board 
and lengthen the bed by boards laid longitudinally, and projecting one 
or two feet beyond the bottom rail. This furnishes a tirm support for 
the mattress. Sometimes, of course, it will be found necessary to lengthen 
the bed. Xo hole is made in the flooring of the bed or of the mattress, 
to provide for fecal evacuations. 

A very comfortable bed. especially for children, can sometimes be 
made from a cot. But it will be necessary always to nail a piece of 
board firmly across the top and bottom of the bedstead when 
the sacking is at its utmost tension, in order to prevent the 
side rails from tailing together. The top board must be nailed 
on vertically, like an ordinary head-board, so as to prevent the 
pillows from foiling off, but the bottom piece, at least one foot 
wide, should be laid horizontally to support and steady the 
apparatus as it extends beyond the foot. 

Having had occasion to assist the late Dr. Treat in the 
management of a fracture of the thigh in the case of a little 
girl not cpiite three years old, I was struck with the simplicity 
and completeness of an arrangement which he had made to 
prevent the bed and the dressings from becoming soiled with 
the urine. It was only to leave directly underneath the nates 
a complete opening through to the floor for the escape of the 
urine, and to protect the margins of the sacking and sheets, 
which came nearly together at the opening, with pieces of 
oiled cloth folded upon themselves. It was found that not 
only the bed was in this way kept dry, but the dressings also; 
it being now observed that the dressings had become wet here- 
tofore by soaking up the moisture from the bed, rather than Standard, 
by the direct fall of the urine upon them. 

Having prepared the bed for the reception of the patient, and elevated 
its lower end about four inches by placing blocks underneath the foot- 
posts, the following additional preparations should be made before we 
proceed to reduce the fracture and dress the limb : 

There should be provided a piece of board of the requisite length and 
breadth, furnished with a slot to receive the pulley, and called the 
"standard," a small iron rod, a pulley, a yard of rope, and a vessel or 
bag t-- receive the weights. 

The -l"t should have sufficient length, and the standard should be 
perforated in the direction of its breadth at short distances, to enable 
the surgeon to elevate or depress the pulley, as may lie required. In 
case ;i metallic pulley cannot be obtained, a spool will answer a- a toler- 
able substitute. We now employ generally, at Bellevue, an iron upright 
rod. with a pulley affixed, and which is made fast t<> the iron frame of* 
the bedstead with two iron clamps, secured in place by screws. They 
may be found at the shops of any of our Instrument makers. A pulley, 
mounted with a screw, may be sometimes substituted, the -crow being 
attached to the foot-board. (Fig. 194.) 

The adhesive plaster which I have generally used both in private ami 



506 



PRACTUKES OF THE FEMUR. 



hospital practice is that which is usually found in drug stores, spread 
upon linen; but Borne of my colleagues prefer the plaster spread upon 
jeans or canton flannel, as being stronger. I cannot, however, appreciate 
their advantage, since the ordinary plaster seldom gives way when 
properly applied. Dr. John B. Brooke, of Reading, Pa., prefers the 
"ordinary pitch plaster," as being "elastic, soft, and firmly adherent," 
and as not excoriating, etc. 

A thin block or piece of board, called the " foot-piece," is to be pro- 
vided, perforated in the centre to receive the cord, and of sufficient 
length to prevent the adhesive strips or "extension bands" from press- 
ing upon the malleoli. An average size for the foot-piece in the case of 
an adult is about three inches and three-quarters in length, by two and 
a half in breadth. 

The adhesive plaster may be cut in the shape shown in the illustration 
(Fig. 196) : five and a half inches wide in the centre, and two and a half 



Fig. 194. 



Fig. 195. 





Iron upright and weight. 
(From Tiemann.) 



Foot-piece. 



inches wide at the narrowest point, and gradually widening again toward 
each extremity to four inches ; the narrower portions being slit down 
two-thirds of their length. For an adult we generally require a strip of 
about four feet and eight Inches in length, namely, sixteen inches for the 
central and widest portion, and twenty inches for each extremity. The 
shoulders of the central portion are cut as represented, in order that when 
folded upon the foot-piece and upon itself it may reinforce the lateral 
bands at their weakest points. 

The lateral or side-splints may be made of thick pieces of gum-shellac 
cloth, of stout leather cut and moulded to the limb, or of thin pieces of 
hoard covered with cotton cloth and stuffed on the sides next to the skin 
with cotton-batting to fit all the inequalities of the limb. Of these 
several materials gum-shellac cloth is much the best. It is thin, light, 
firm, and after immersion in hot water can be sufficiently moulded to the 



F R A C T l~ R E S P T BE SHAFT OF THE FEMUR. 



507 



contour of the thigh. The cotton cloth must be stitched over the splints 
like a sac. but left open at the ends until the padding is properly ad- 
justed. Loose cotton-batting always becomes displaced. Four splints 
are generally required : one for the anterior surface, extending from the 
groin below the anterior inferior spinous process of the ilium to within 
half an inch of the patella: one for the posterior surface, extending from 
the tuberosity of the ischium to a point six or eight inches below the 
knee: one for the inside, extending from near the perineum to the inner 
condyle : and one for the outside extending from above the trochanter 
major to the outer condyle. These splints ought to encircle the limb 
almost completely, only leaving an interval of from half an inch to one 
inch between each of the adjacent splints. The outer and inner splints 
may be extended below the knee when the fracture is low down; but in 

Fig. 19G. 




Extension-band and foot-piece. 



that case they must be carefully fitted to the irregularities of the con- 
dyles. The posterior splint is the most important of them all. It should 
be wider ami much longer than either of the other splints, and it must 
be fitted with great accuracy to the back of the thigh, ham, and upper 



Fig. 197. 



Same, folded and ready for use. 

part of the leg. It is important also to cover this with a sac of cotton 
cloth so that it may be stitched to the centre of the bands, which are to 
inclose all the splints. If this is not done, it is very liable to become 
displaced. 

A long side-splint must now be prepared, long enough to extend from 
about four inches below the axilla to five inches below the heel ; four 
and a half inches wide, by half an inch in thickness, and provided with 
a cross-piece ;it tin- lower end. two feet long by three inches wide and 
half an inch thick. The purpose of this splint is not to make extension, 
but to prevent the femur from becoming bent outwards at the seat of 
fracture: which is accomplished more certainly by this splint than by 
the short splint-, inasmuch ;i- i1 keeps the whole body, including the 
upper part of the femur, in ;i straight line. [ts purpose is also to pre- 
vent eversioD of the foot, which purpose is never accomplished effectively 
by junks or by any other method I have yet seen adopted. It is t<> be 
employed in nil fractures of the thigh, including fractures of the neck. 
The inner surface of this long splint musl be padded throughout it< \\ hole 
length, and thus fitted accurately to the Bides of the body and limb. 

Four or six strips of cotton cloth, each two inches wide by one yard 



508 



FRACTURES OF TJ1E FEMUR. 



iii length, are stitched by their centres to the back of the posterior splint, 
and these are laid upon the bed in position to receive the limb. 

Supplied with rollers, several additional strips of bandage, and cotton- 
batting, Ave are now ready to reduce and dress the fracture. 

The patient being placed in position upon the bed, one assistant seizes 
the limb by the knee, and a second by the foot, drawing upon it firmly 
and steadily, at the same moment lifting it from the bed so as to render it 
more accessible ; while the surgeon lays the extremities of the extension 
strip upon each side of the leg, with the centre, containing the foot-piece 
and the rope, about one inch below the sole of the foot. With a 
muslin roller, inclosing the limb from near the metatarsophalangeal 
articulation to the tuberosity of the tibia, the adhesive strips are held in 
place. As a rule, and especially in the case of women, and of persons 
of a delicate lax fibre, it is well to lay against the tendo Achillis, and 
over the instep, a little cotton-batting before applying the roller. In 
some cases I am in the habit of applying a thin sheet of cotton-wadding 
over the whole surface of the limb. Any excess of the bands at the 
upper end is disposed of by turning the ends down, and inclosing them 
in a few additional turns of the roller. As soon as the application of 

Fig. 198. 




Mode of applying adhesive plaster. (When the dressings are completed, the limb is to 
rest on the bed.) 



the adhesive strip and roller is completed, the weight may be adjusted, 
and extension applied. The amount of extension required for adults 
will vary from eighteen to twenty-three pounds. In a large proportion 
of cases, twenty of twenty-one pounds will be borne without complaint; 
and the ability of the patient to tolerate the extension, alone limits the 
amount. Occasionally, even a few pounds, when first applied, cause 
pain in the ligaments about the knee-joint; but in a few hours the 
amount may be increased. It is better to apply eighteen or twenty 



FRACTURES OF THE SHAFT OF THE FEMUR. 



509 



pounds at once, if it can be borne Lifting the knee slightly by a pad 
placed underneath will often relieve the pain caused by the extension. 

Sometimes, in the case of very muscular patients, and where the 
primary shortening is considerable, I believe we make a positive and 
permanent gain if we place the patient under the influence of chloro- 
form for a few minutes when the weight is first applied. In these cases, 
as in dislocations, I generally prefer chloroform to ether, for the reason 
that the patient is less liable to muscular contractions when he is passing 
under the influence of the anaesthetic. 

Extension being effected, and the patient already resting upon the 
posterior coaptation splint, the three other side-splints are applied, and 
the whole four secured in place by the four or six transverse bands 
already described as attached to the posterior splint ; the bands being- 
tied over the front splint firmly. 

It remains only to lay the long splint beside the body, and to secure 
it in place by separate strips of bandage. Three strips for the leg, one 
broad strip for the pelvis, and one for the chest, are all that are required. 
The leg strips may be drawn pretty firmly to prevent all outward rotation 
of the limb. The pelvic band also ought to be tight enough to insure the 
constant contact of the pelvis with the long splint ; but the thoracic band 
may be rather loose, as its function in this respect is not so important. 
One broad band may be substituted for the two latter, which should be 
sewed to the cover of the long splints to prevent its becoming displaced. 
In the drawing (Fig. 199), narrow strips inclose the thigh and long 
splint, but I often omit them as being unnecessary ; indeed, it is better 
sometimes to omit them when the fracture is high up, lest they should 
• 

Fig. 199. 




Author's dressings for fracture of shaft of femur, complete. (The long splint 
extends nearly to the axilla.) 



hold the lower fragment out. when the pelvis was not firmly secured to 
the long splint: in which case the other fragment might incline in the 
opposite direction, causing thus a bowing out at the point of fracture. 
The patient's pillow must rest under fche head alone, in order that the 



510 FRACTURES OF THE FEMUR. 

whole weight of the body, from the shoulders down, may be employed as 
a means of counter-extension. Omission of this important precept will 
sometimes permit the body of the patient to descend toward the foot of 
the bed, even when the foot of the bedstead is raised. 

During the first four or five weeks the patients should not be allowed 
to rise or to sit up in bed. It is an error to suppose that such restraint 
is irksome. In my experience, no patient has ever complained of it ; 
and 1 have no doubt that such movements increase the danger of non- 
union ; a misfortune which has never happened when a patient has been 
under my treatment from the first to the last. I have, however, seen 
several cases of non-union, or of delayed union, in the practice of other 
surgeons, which I attributed to the patient having been permitted to rise 
in bed. For this reason, also, I reject all modes of treatment which are 
intended to permit these motions of the body, such as Burges's fracture- 
bed. 

In order to evacuate the bowels, the patient may draw up the sound 
limb, when a property constructed bed-pan is easily placed under the 
nates. This occasions no disturbance to the fracture. ' 

From the time of the first dressing the patient should be seen daily, 
and the coaptation splints loosened or tightened from time to time, as 
may seem necessary. To open the limb, and even to remove tempora- 
rily all the coaptation splints except the posterior one, is harmless, and 
it is often a source of comfort to the patient. Ordinarily it is not neces- 
sary or prudent to disturb the extension until the union is completed. 
The usual time required for consolidation in the case of an adult is from 
six to eight weeks ; but if the bone feels pretty firm at the end of four 
weeks, the extension may be a little relaxed. When at length the 
patient is permitted to leave his bed, a pair of crutches is indispensable ; 
and during the following two months but little weight should be borne 
upon the limb. 

Fractures of the thigh in children have generally been found more 
difficult to manage than fractures of the same bone in the adult, owing 
chiefly to the shortness and softness of the limb, the delicacy of the skin, 
its liability to become excoriated, or to become soiled, and the restlessness 
of the patient. I have tried nearly all forms of apparatus in these cases, 
including double-inclined planes, boxes, single long splints, etc., and the 
result of my experience is that they are all inefficient ; and for some 
years I have employed a mode of dressing, partly my own and partly the 
suggestion of others, but of which I am able to say that it never disap- 
points me in the result obtained ; while it is simple, easy of management, 
and comfortable to the little patients. 

Extension by means of adhesive plaster and a weight employed in the 
same manner as in adults, constitutes a valuable aid in many cases ; but 
I cannot say that it is indispensable, since, with children under five or 
seven years, the fractures are pretty often so nearly transverse that, 
when once reduced and well supported by lateral splints, union without 
shortening may generally be expected ; but these results become less 
and less frequent as we advance toward adult life. It is safe and proper, 
according to my experience, to employ in any case extension, somewhat 
according to the following rule. One pound for a child one year old, 



FRACTURES OF THE SHAFT OF THE FEMUR. 



511 



two for a child two years old, and so on, adding one pound for every 
year up to the twentieth. Of much more consequence, however, is it to 
confine, at the same time, both limbs, for as long as one is at liberty it 
is almost impossible to secure any degree of quiet. It is of equal im- 
portance, in my opinion, to give to the limbs an extended rather than a 
Hexed position. 

My plan of treatment, therefore, in the case of children, is in all 
essential respects the same as in adults, except that instead of one long 
side-splint, I employ two. The accompanying illustrations will explain 

Fig. 200. 



Author's splint for fracture of the femur in children. 

more fully my meaning. Two long side-splints connected by a cross- 
piece at the lower ends, and reaching upwards to near the axillae, sepa- 

Fig. 201. 




Author's dressing for fracture of the femur in children, complete. 

rated a little more widely below than above, so as to render the perineum 
more accessible, are laid upon each side of the body. The four short 
thigh splints, made of binders' board and covered with cotton cloth, are 
secured in place by four or five strips of bandage tied in front and then 
stitched to the cover- of the splints. These must not embrace the long 
Bide-splint. The broken limb below the knee, and the opposite thigh and 
leg an- then secured to the long splints by separate and broader strips of 
cloth. My object in substituting, in this case, separate -trips for the 
roller, is to render the limb more accessible to the surgeon, to enable him 
more readily to remove portions which are soiled, and to leave the leg 



51:2 FRACTURES OF THE FEMUR. 

more free to be drawn downwards, in case permanent extension is em- 
ployed. 

Thus Becured and laid upon a bed, such as I have already described 
as appropriate for children, the least possible annoyance will be given 
to the surgeon. The dressings are but little liable to become wet with 
urine, and when the bed is soiled, the child can be taken up with the 
splint and carried to another ; indeed, this may be done as often as the 
patient becomes restless or weary, without any risk of disturbing the 
fracture. 

In case the surgeon desires to use extension with adhesive plaster 
and weights, the necessary apparatus may be made fast to the bedstead, 
and taken off when the child is moved ; or it may, if thought best, be 
made fast to the foot-piece of the splint. 

Occasionally, with children, I employ, as a means of extra safety, a 
perineal band, drawn moderately tight, and fastened to the top of the 
splint on the side corresponding to the broken limb. The best perineal 
band is a piece of soft cotton cloth, one or two yards long by three 
inches wide, folded lengthwise to a flat band of one inch in breadth, 
and inclosing, where it passes through the perineum and under the 
nates, a few thicknesses of paper. The paper prevents its drawing into 
a round cord. Sometimes I place between the paper and the folded 
cloth, on the side which is to be laid next to the skin, one or two thick- 
nesses of cotton-wadding. To absorb the moisture, it is well to lay a 
piece of sheet lint between the band and the skin. The perineal band 
may be removed daily and renewed ; and the perineum examined and 
washed. 

Four or five weeks is generally a sufficient length of time for perfect 
consolidation, in children under five years of age. 1 

If I have been unable to give my approval to the treatment of frac- 
ture of the shaft of the femur in adults with plaster of Paris, or to any 
other form of immovable dressing, I am still less able to give it my ap- 
proval in fracture of the same bone in children. The following case will 
illustrate its dangers : A boy, four years old, fell thirty feet, breaking 
his right thigh near its middle, causing one of the fragments to protrude 
through the flesh. The surgeon in charge, having reduced the fracture, 
applied on the fifth day a plaster-of-Paris splint from the toes to the 
groin, leaving a fenestra opposite the wound in the thigh. The child 
Buffered much pain that night, and on the following morning his toes 
were cold. On the second morning after the dressing there were vesica- 
tions on the toes. On the fourth day the toes were discolored, and an 
offensive odor escaped from the dressings. The dressings were now 
removed, and the toes, with a part of the foot, were found to be gan- 
grenous. Subsequently the gangrene extended to the middle of the leg. 
This case had been seen and the condition of the toes noted each day by 
the surgeon, but he did not become alarmed until the fourth day. The 
surgeon in attendance was then dismissed and another called, by whom I 
was immediately consulted, at my house, as to the proper course to be 

1 Fractures of Shaft of Femur in Children. A clinical lecture bv the author at 
Bellevue, Med. Eec., Jan. 5, 1878. 



FRACTURES OF THE SHAFT OF THE FEMUR. 513 

pursued. I advised the continuous hot water bath as preferable to am- 
putation under the circumstances, in accordance with my published expe- 
rience in numerous cases of traumatic gangrene. 1 The surgeon adopted 
my suggestion, and in about three weeks the limb separated spontane- 
ously, the gangrene having never extended after the limb was submerged 
in the bath. His recovery has been complete. 2 

In 1877. Dr. Schede, of Berlin, adopted a method of treating frac- 
ture of the thigh in children, which he calls ''vertical extension." Dr. 
Kiimmel, 3 of Hamburg, endorses the practice, and has reported twenty- 
eight cases treated by this method, twelve of the patients being less than 
a year old, and sixteen between the ages of one and two years; the 
usual result being union within three w T eeks, without shortening or dis- 
placement. 

The method of treatment is as follows : "A long continuous band of 
plaster is fixed to both sides of the injured limb, as high as the seat of 
fracture, and applied so as to form a free loop below the sole. This long 
strip is then secured in the ordinary way by circular strips of plaster, 
and by circular turns of a bandage. The leg, having been elevated, is 
then kept in the vertical position, with the corresponding side of the 
pelvis suspended by means of a piece of cord fixed to the loop of plaster, 
and either attached above to some object over the bed, or slung over a 
pulley, with its free extremity supporting a weight." This does "not 
necessitate constant and complete rest on the back." At the end of 
about three weeks, when the fragments are usually consolidated, the ex- 
tension is removed, and the limb is permitted to rest upon the bed. 

It must be understood, however, that with any mode of treatment, 
almost, occasional good results are obtained ; but this is only because 
fractures of the thigh in infants are generally green-stick fractures; and 
the tendency to displacement is very slight, and union occurs very 
speedily. On the other hand, when these fractures have been treated by 
plaster of Paris, double-inclined planes, simple side-splints, etc., every 
now and then the results have been very bad, and sometimes disastrous. 

One need not be surprised, therefore, that Dr. Schede, or any other 
practical surgeon, rather than employ the usual methods, should adopt a 
plan so entirely novel and radical. As between his method and most 
other methods, I do not hesitate to say at once that his is, in my opinion, 
by far the best 

The advantages claimed by Dr. Kiimmel for Dr. Schede's method are, 
that it does not necessitate constant and complete rest upon the back ; 
and that it is simple, efficient, and does not cause pain or discomfort to 
the patient. 

The only disadvantage stated is the occurrence, in some cases of 
female-, of a severe vaginal catarrh, due, as is supposed, to the free en- 
trance of air into the gaping ostium vaginae; but which is quite as likely 

1 Warm and Hot Wafer in Surgery. By my late pupil, Dr. Fred. E. Hyde. Buff. 
Med. Journ., Dec. 1875; Tran-. X. V. State Med. Soc, 1< S 7~>; Richmond and Louis- 
ville Mod. Journ., Jan. 1874; New York Med. Rec., May 15, 1874, with various 
other papers by the author. 

- Medical Record, March 15, 1879, )>. 257, case reported hy Dr. Forest. 

3 Schede, Kiimmel, Berliner Klin. Woeh., No. 4, 1882. 

33 



514 FRACTURES OF THE FEMUR. 

to be the result of the lateral stretching of the labia as of the entrance 
of air. 

I shall be excused if I institute a brief examination of the merits of 
tli is method as compared with the merits of the method of horizontal 
extension recommended and adopted by myself. 

Dr. Kummel has very frankly stated one objection which does not 
apply to horizontal extension, namely, a severe vaginal catarrh ; and this 
alone would be sufficient objection, in my opinion, to its employment in 
the case of females. Admitting that it will prove, in most cases, to be 
only temporary, yet it may not in certain constitutions or habits of body 
cease with the removal of the cause ; and no assurance can be given 
that the inflammation may not be propagated upwards, and thus lay the 
foundation of serious future uterine trouble. The mere possibility of 
such a result is sufficient to condemn the practice, as applied to this class 
of cases. 

A second objection I find in the fact that by Schede's method the 
patient is during the entire period of treatment confined to the bed, 
while in horizontal extension he is not. 

Singularly enough, almost this same argument is employed by Kiim- 
mel in favor of Schede's method. " It does not necessitate constant 
and complete rest on the back." In other words, the patient may turn 
over more or less upon his side without disturbing the fracture. This 
statement, it is evident, must be received with some reserve. In a large 
proportion of cases where the children are under two years the fracture 
is a green-stick fracture, and often it may be termed a mere bending of 
the bone ; and in all such cases a certain freedom of motion may be 
permitted without causing either lateral or rotary displacement ; but 
there must be a limit to the freedom of motion of the body even in 
these cases. 

The case is very different, however, when, as occasionally happens — 
pretty often, indeed — the fracture is complete, and the fragments have 
been once permitted to overlap or slide upon each other in the direction of 
the axis of the bone. In such cases there could be no assurance given, 
where the patient was subjected to no restraints whatever, that union 
might not be delayed ; and, in some cases, that the fragments might not 
unite with some degree of rotary displacement. No doubt the close 
apposition of the muscles will tend to prevent this unfortunate occur- 
rence to a great extent ; but then, it seems unnecessary to say, the 
danger of its occurrence is greater where such perfect freedom of motion 
is permitted. 

If, however, it were to be conceded that some motion of the body is 
admissible, and that Schede's method permits the patient to relieve the 
back by turning occasionally upon the side, still it must be observed that 
the extension apparatus, upon which Schede alone relies to adjust and 
retain the fragments, does not permit the patient for one moment to 
leave the bed. In Schede's method the extension apparatus is a fixture, 
and its position cannot be changed, nor can it ever be relaxed. 

On the other hand, in horizontal extension the body is not indeed per- 
mitted to roll from side to side, but the patient, inclosed in the splint, and 
including even the extension apparatus, may be taken from one bed to 



FEACTUEES OF THE SHAFT AT THE CONDYLES. 515 

another, or taken out of doors, as often as we choose. The patient may 
be put temporarily into almost any position which necessity or comfort 
may require. 

Further than this, in horizontal extension the surgeon does not rely 
solely upon the extension made by weight and pulley, to keep the frag- 
ments in line, so that these may at any time be temporarily removed 
without affecting the result. Indeed, in many cases this portion of the 
apparatus is not employed by myself; and I sometimes omit also the 
lateral splints. 

Xor is it so irksome for infants to lie on their backs three or four 
weeks if only they be permitted to use their hands, as some would sup- 
pose. In fact, after the first day they seem perfectly reconciled to it ; 
while, if permitted to move, they are for a time constantly causing 
themselves pain by some sudden twist of the limb. 

I have not spoken of the inconvenience which must be experienced in 
the vertical extension in the adjustment of the coverings, and especially 
in cold weather, which inconvenience is avoided in horizontal extension. 

It must be added, also, that although in children of this age the frag- 
ments are usually firm in three or four weeks, it has not been found 
safe, in my experience, to remove wholly restraints until a week or two 
later. The contrary practice has every now and then resulted in a 
bending at the seat of fracture, which had subsequently to be remedied. 
My double splint, with only moderate confinement of the body and 
limbs, without extension or short splints, prevents this unfortunate acci- 
dent in the later days of the treatment, while in Schede's method the 
limb must be left, after the extension is removed, wholly without support. 
In one of Kiimmel's patients the extension had to be continued 104 
days, and in another 111. 

Finally, if we are to compare results, no evidence is presented by 
Kuinmel that his results are any better than my own, by which latter 
method rotary displacement is impossible ; lateral displacement or bend- 
ing, improbable ; and there is no shortening, of course, unless it is a 
complete fracture, and if it occurs then it is trivial. 

The treatment of compound fractures of the thigh, caused by gunshot 
injuries, will be considered in the chapter devoted to Gunshot Fractures. 
Other badly comminuted and compound fractures of this bone are to be 
managed upon the same general principles as gunshot fractures. 

Those compound fractures of the femur which have been caused by 
the thrusting of the sharp fragments through the flesh, and in which 
reduction has been easily effected, have in most cases done as well as 
simple fractures, except that the limb is generally a little more shortened. 
The wound usually soon heals, and the future progress of the case is the 
same as that of a simple fracture. They may be treated, therefore, in 
the same manner as those which have just been described. 

§ 5. Fractures of the Shaft, at or near the Base of the Condyles. 

These fractures are not so common as fractures of the shaft elsewhere. 
Only twenty examples are contained in my records as having come under 
my personal observation. Malgaigne thinks they are caused generally 
by direct blows, but this was not Sir Astley Cooper's opinion, and ac- 



516 



FRACTURES OF THE FEMUR. 



Fig. 202 



cording to my own experience they are caused generally by a fall upon 
the knees or feet. In at least nine of the cases seen by me the fracture 
waa caused in this manner, and in seven it is known that the fracture 
was caused by a direct blow. 

The direction of the line of fracture is generally from behind forwards 
and downwards, the upper fragment being driven downwards toward the 
patella ; in other cases the line of fracture preserves the same general 
direction, but inclines inwards or outwards ; and in these cases the upper 
fragment is found lying more or less on the inner or outer margins of 
the knee, probably most often on the inner side. 

In one instance I have found both femurs broken at the same point 
and in the same manner. Mr. L. Brittin, aged about forty-five years, 
while employed upon a building, fell from a fourth-story window upon 
the stone pavement below, striking upon his feet. In addition to several 
other fractures, I found both femurs broken obliquely downwards and 
forwards, just above the condyles. Very little inflammation ensued, and 
although it was found impossible to employ extension, union occurred 
readily, and with only a moderate overlapping. 
In the left limb, however, the upper fragment 
pressed down sufficiently to interfere some- 
what with the patella, and the patient was 
unable, after several months, to straighten the 
knee completely. The motions of the right 
knee were unimpaired. 

I have only once met with a fracture at 
this point in which the line of separation was 
downwards and backwards. As the case 
presents several points of interest, it will be 
proper to narrate the facts somewhat at length. 
George Taylor Aiken, of Lockport, N. Y., 
;et. 7, on May 18, 1854, in jumping down a 
bank of about three feet in height, broke the 
right thigh obliquely, just above the knee- 
joint. Direction of the fracture obliquely 
downwards and backwards. 

Dr. G., an accomplished surgeon, residing 
in Lockport, was called. The limb was not 
then much swollen. He applied side-splints, rollers, etc., carefully, and 
then laid the limb over a double-inclined plane. The knee was elevated 
about six or eight inches. Before applying the splints, suitable exten- 
sion had been made, and after completing the dressings, the two limbs 
seemed to be of the same length. 

On the second or third day, Dr. G. noticed that the toes looked un- 
naturally white, and were cold. 

Counsel was now called at the request of Dr. G., when it was deter- 
mined to abandon all dressings, and direct their efforts solely to saving 
the limb. 

The result was that slowly a considerable portion of his foot died and 
sloughed away, leaving only the tarsal bones. The fracture united, but 
witli considerable overlapping and deformity. 




Fracture at base of condyles. 



FRACTURES OF THE SHAFT AT THE COXDYLES. 517 

Feb. 26, 1856, the boy was brought to me by his father. On exam- 
ining the fracture, I noticed that the anterior line of the femur seemed 
nearly straight, and this appearance was owing in some degree to the 
muscles which covered and concealed the bone, and in some degree, 
also, to the manner in which the fragments rested upon each other ; the 
pointed superior end of the lower fragment resting snugly upon the 
front of the upper fragment, so that no abrupt angle existed in front. 
On the back of the limb, however, the lower end of the upper fragment, 
quite sharp, projected freely downwards and backwards into the popliteal 
space, so that its extreme point was only about half an inch above the 
line of the articulation. The limb had shortened one inch, and this 
enabled us to determine accurately that the lower point, or the com- 
mencement of the fracture, was one inch and a half above the articula- 
tion, while the point where the line of fracture terminated in front was 
probably quite three inches and a half above the joint. 

The motions of the knee-joint were pretty free. The leg was ex- 
tremely wasted, and the anterior half of the foot having sloughed off, the 
sores had now completely healed over. He was able to walk tolerably 
well without either crutch or cane. 

Subsequently, Dr. G. found it necessary to sue the father of the child 
for the amount of his services, when Mr. Aiken put in a plea of mal- 
practice, and that consequently the services were without value. 

The case was tried in the March term of the Niagara circuit of 1856, 
at Lockport. X. Y., the Hon. Benjamin F. Greene presiding. 

On the part of the defence, it was claimed that the death of the foot 
was in consequence of the bandages being too tight. They failed, how- 
ever, to show that they were extraordinarily or unduly tight. While on 
the part of Dr. G., the prosecutor, it was shown that the death of the 
toes was preceded by a total loss of color, and that it was not accompa- 
nied with either venous or arterial congestion. The medical gentlemen 
examined as witnesses declared that this circumstance furnished the most 
positive evidence which could be desired that the death of the toes was 
not due to the tightness of the bandages, but that its cause must be 
looked for in an arrest of the arterial or nervous currents supplying the 
limb, or in both. They believed, also, that the projection of the superior 
fragment into the popliteal space was sufficient to cause this arrest. 
Tiny also believed that overlapping and consequent projection could not 
have been prevented in this case, and that therefore the treatment was 
not responsible for this unfortunate result: indeed, they regarded the 
treatment as correct, and the result as a triumph of skill, in that any 
portion of the limb was saved : the leg and foot now remaining being far 
more useful than any artificial leg and foot could be. 

The lion. Judge, in a speech remarkable for its clearness and liber- 
ality, sought to impress upon the jury the value of the medical testi- 
mony. The jury returned a verdict for Dr. (}.. allowing the amount of 
his claim for services, with the cost of suit. 

Specimen 121, in Dr. Marsh's collection at Albany, presents a similar 
disposition of the fragments. The fracture is oblique, from above down- 
wards and backward-, and the upper portion lie- behind the lower. It 
is firmly united by hone, but with an overlapping of from two and a half 



518 FRACTUKES OF THE FEMUR. 

to three inches. The young gentleman who showed me the specimen 
remarked that it had been found impossible, owing to an ulcer upon 
the heel, and to other causes, to employ in the treatment any degree of 
extension. 

These two are the only examples which have come under my observa- 
tion in which a fracture at this point has taken this direction. 

Sir Astley Cooper does not seem to have recognized this form of frac- 
ture and displacement. Amesbury has, however, recorded one case, 
which came under his own observation, where, although the bloodvessels 
and nerves escaped, the bone projected through the skin in the ham, and 
finally exfoliated. 1 And he thinks the point of bone may sometimes 
so penetrate the artery and injure the nerves as to render amputation 
necessary, in order to save the life of the patient. 

M. Coural also has related a case in which an epiphysary disjunction, 
occurring in a child twelve years old, was attended with a displacement 
of the upper fragment backwards, and amputation became necessary. 2 

I know of no other cases of this rare accident which have been re- 
ported. Lonsdale refers to it as "the rarest direction for a fracture to 
take ;" and thinks that in case of its occurrence, the vessels in the pop- 
liteal space will stand a chance of being wounded ; but he mentions no 
example. The popliteal artery hugs the bone so closely at this point, 
that a displacement of the upper fragment in a direction downwards and 
backwards must always greatly endanger its integrity. Indeed, it is 
here that the artery and vein are in the closest contact with each other, 
and with the bone; an anatomical fact which has been used by Rich- 
erand and others to explain the greater frequency of aneurisms in the 
ham. 

The prognosis in this fracture has, according to my own experience, a 
wider range than in the case of other fractures of the shaft. In a pro- 
portion of cases the union has been effected with little or no shortening ; 
a result which is not surprising when we consider that at this point the 
muscular resistance which has to be overcome is less than at any other 
point of the shaft of the femur ; and that occasionally the line of frac- 
ture is so little oblique that the fragments being once adjusted support 
themselves completely. Malgaigne says that here " oblique fractures 
are more rare" than those which are nearly transverse; but Sir Astley 
Cooper had never met with a transverse fracture at this point, nor have 
I ; yet no doubt they do occur here more often than in other portions of 
the shaft. Malgaigne says that M. Denonvilliers thought he had found 
in the Dupuytren Museum four or five examples of exactly transverse 
fractures at this point, but he had not found one higher up. 

Malgaigne, who I infer has examined these specimens, does not seem 
to be satisfied that they represent really transverse fractures, but he does 
not speak positively upon this point. 

James A. Manly had his right thigh broken at this point when he was 
four years old, and when lie was thirty years old I found it shortened 
half an inch, but the point of fracture could be distinctly felt. That it 

1 Remarks on Fracture?, etc., by Joseph Amesbury, vol. i. p. 293. London, 1831. 

2 Archiv. Gen. de Med., torn. ix. p. 267. 



FRACTURES OF THE SHAFT AT THE CONDYLES. 519 

was not an epiphyseal fracture I was assured by the fact that the bone 
had not ceased to grow in this direction, and by observing that the frac- 
ture was too high to warrant such a supposition. 

Andrew Carr, aet. 25, treated at the New York Hospital, had a short- 
ening of three-quarters of an inch. 

Mrs. Jackson, aged about thirty, had a shortening of one inch. Both 
of these latter patients were treated in the straight position, but without 
permanent extension, and therefore did not represent the best results 
which might be obtained. 

John Van Pelt, set. 51, treated by me at Bellevue Hospital in 1873, 
with plaster of Paris, and, therefore, without permanent extension, had 
a straight limb, and the shortening was half an inch. This fracture was 
caused by a fall upon his foot, and the lower end of the upper fragment 
was thrust through the flesh and skin, making a small hole in the latter; 
but this soon closed, and the case proceeded as if it had been a simple 
fracture. 

In the following case there was no shortening, but the limb was, after 
the union, longer than the other : Michael Halloran, set. 40, had his left 
femur broken by a direct blow, three inches above the joint, October 6, 
1871. Having been received into my wards at Bellevue, my own ex- 
tension apparatus was applied by my house surgeon, Dr. Lewis, with 
weight and pulley, and continued seven weeks, when the fragments were 
found united ; the limb being half an inch longer than the other. This 
measurement has been repeated several times by myself and others with 
the same result. 

I have mentioned the very satisfactory result in the case of Brittin, 
with a double fracture. 

Of the following case it seems proper to say, whether the shortening 
is no greater than I have been informed or not, that the result is cer- 
tainly very favorable considering the character of the accident : 

Col. A. Alden, of Troy, was blown up in the explosion of the maga- 
zine at Fort Fisher, Jan. 19, 1863. I saw him in consultation with Dr. 
Simmons. U. S. A., at Bedloes Island, on the eighth day after the acci- 
dent. The right thigh was broken above the condyles, the upper frag- 
ment being thrust down in front, and to the inner side. Both limbs were 
greatly bruised, swollen, and discolored. His right thigh was at this 
time shortened four inches. At my suggestion, Buck's extension was 
applied. He was never seen by me again, but his brother wrote me 
April 28, 1865, that the Colonel (then General) had returned to his com- 
mand with the limb shortened only half an inch. As I do not under- 
stand this measurement to have been made by a surgeon, it cannot be 
regarded as authoritative. 

The following two examples do not present results equal to the average 
of* fractures of the shaft of the femur in other portions : 

W. C. Latham, get. 35, treated chiefly by plaster of Paris: when he 
consulted me after five months the Limb was shortened one inch, and the 
knee-joint almost completely anchylosed. 

Sannn-l Wilson, set. 47. fell from a car. striking upon his knee, lie 
was placed under my care at Bellevue, and at firsl laid upon a double- 
inclined plane: but this being found very uncomfortable, and not im- 



520 FRACTURES OF THE FEMUR. 

proving the position of the fragments, extension, with weight and pulley, 
was substituted. The union was effected with a shortening of one inch, 
hut with very little anchylosis of the knee. 

Henry II oft". Bet. 40, received a comminuted fracture of his left thigh 
four inches above the knee, from a direct blow, Dec. 2, 1879 ; fracture 
oblique. He was treated in my wards at Bellevue by extension and 
weights. It united in a straight position, but shortened one inch. 

Anna Simpson, set. 16, broke her right femur Dec. 12, 1879, by a fall 
from a rope thirty feet. Shortening at time of admission to Bellevue 
one inch and a half, showing that it was probably from a fall on the foot 
or knee. She was treated in my wards by my mode of extension. 
There is now union with less than half an inch shortening. The motions 
of the knee-joint are free. 

I have taken the pains to mention these fortunate cases more in detail 
than their simple character would seem to justify, because I w T ish to place 
them in contrast with the less fortunate cases. 

Mrs. Catharine Sullivan, aet. 55, a large, fat woman, fell from a height, 
striking probably the right knee. The fracture was compound ; and 
when admitted to my service at Bellevue, October 9, 1866, the limb was 
greatly swollen. Immediate amputation was urged, but she refused to 
have it done. Moderate permanent extension was then employed, and 
suitable dressings applied ; suppuration occurred in the knee-joint, and 
she died in about two weeks. 

Michael O'Shea, aet. 40, had his right thigh broken at the same point 
by the fall of a piece of timber upon it, and was admitted to my service, 
in the Buffalo Hospital of the Sisters of Charity, on the same day. He 
refused to submit to amputation, and he died on the tenth day, after 
gangrene had ensued. 

I was called to see a gentleman in AYaverly, Tioga County, who was 
thrown from his carriage February 20, 1864, striking on both knees, 
causing a fracture of the right thigh above the condyles. On the sixth 
day. in order to establish the diagnosis, his surgeon administered chloro- 
form, and examined the knee thoroughly ; but he was seized with a 
tetanic convulsion while they were manipulating ; subsequently he had 
other similar convulsions. I saw him on the ninth day, when the limb 
was greatly swollen, and his general condition seemed to indicate speedy 
death. The convulsions still continued. The limb was shortened one 
and a half inches as it lay reposing upon a double-inclined plane — 
Daniels's fracture-bed. A few days later he died. 

The case of Aiken, in which the line of fracture was from above, down 
and back, already described at length, was followed by gangrene, and 
resulted in amputation. This was treated on a double-inclined plane. 

Daniel Welsh had his thigh broken by a direct blow just above the 
knee, when he was twenty years old, in Ireland. The fracture was 
compound and comminuted, and some fragments of bone subsequently 
escaped. He was examined by me five years later, when I found the 
limb shortened seven inches. My notes do not refer to the method of 
treatment. 

Wm. Hennen consulted me in February, 1854, complaining that his 
leg had been treated badly, and that he was in consequence very much 



FRACTURES OF THE SHAFT AT THE CONDYLES. 521 

maimed. His leg had been broken by being caught between a carriage 
and a tree. His surgeon had extenson made by four strong men, and 
three long side-splints were bound to the limb ; but there was no perma- 
nent extension. I found the limb shortened more than one inch and a 
half. (Both of the preceding cases were reported in the Trans, of the 
Amer. Med. Assoc, for 1857, in my paper on Deformities, etc.) 

John Bohan, a?t. 37. was admitted to my service, May 11, 1878, 
having fallen down an elevator and striking upon his right knee. When 
admitted the limb was greatly swollen, and the existence of a fracture 
was not recognized. Subsequently I discovered that the right thigh was 
broken just above the condyles, and the line of fracture was from below 
upwards, backwards, and slightly outwards. His legs were covered with 
open ulcers, and extension by adhesive strips was impossible. After 
several attempts to adjust the fragments by extension, flexion, etc., his 
limb was placed in a Hodgen's suspension splint; but this was removed 
five days later, as it was found not to diminish the shortening, and it 
failed equally to prevent eversion of the foot. Having decided that it 
was impracticable to maintain extension, it was determined to do what 
lay in our power to prevent eversion, to which the foot and leg were 
greatly inclined on account of the riding of the upper fragment upon the 
inner side of the lower. This was accomplished very satisfactorily by 
a long side-splint, well cushioned, and bound to leg, thigh, and body. 
Union was effected with a shortening of two inches and three-quarters. 

Mary Tobin. set. 50, fell seven feet, November 6, 1867, and on the same 
day was admitted to Bellevue with a fracture at the base of the condyles 
of the right femur, in the usual direction. We found her thin, pale, and 
covered with syphilitic eruptions. 

Buck's extension was applied with eight pounds. On the 10th this 
was increased to twelve pounds. December 1st, twenty -four days after 
the injury was received, the fragments not having then united, my suc- 
i -. Dr. Wood, took charge of the case. She was at once placed upon 
a double-inclined plane. This was continued a few days, when the frag- 
ments being in a worse position than before, the straight position was 
resumed. About seven weeks after the injury the fragments were not 
united, and Dr. Wood cut the quadriceps. 

February 2d, nearly three months after the accident, it was not united. 
On the 25th it was thought to be united, with a shortening of one and a 
half inches. I did not examine her at this time. 

Joshua Marquand, jet. 70, fell down a flight of stairs and received a 
fracture of the left femur, near the condyles, November, 29, 1879. On 
the same day lie was admitted to Bellevue. We found the limb shortened 
two inches; and the lower end of the upper fragment bad penetrated 
the quadriceps, and lav directly under the skin. An attempt was at 
once made to reduce the fracture by extension of the leg in the extruded 
and flexed position, but without any effect, until the patient was placed 
under the influence of ether; when, under flexion and extension, the 
sharp end of the bone was seen to recede a little, but it still remained 
entangled in the tendon of the quadriceps. An extension apparatus waa 
now applied with twenty pounds, by which the length of the limb was 



O'l'l FRACTURES OF THE FEMUR. 

much increased. On the tenth day Hodgen's suspension apparatus was 
substituted. 

Dec. 19, twenty days after the accident, finding no improvement in 
the condition of the fragments, and feeling assured that union would not 
take place, after consultation held with my colleagues it was decided to 
resect the projecting point of bone, and reduce the fracture. This was 
accordingly done by myself on the same day; one inch and a half of the 
pointed extremity of the upper fragment being removed. Even then it 
was with some difficulty released from its entanglement, and restored to 
its proper position. The limb was dressed with a plaster-of-Paris splint, 
with a fenestra opposite the wound. On the following day the plaster 
splint was opened on account of the occurrence of swelling, and three 
days later the symptoms assumed a grave aspect, gangrene having oc- 
curred over his sacrum and several other parts of his body. He died 
Dec. 25. 

It will appear, then, that while a considerable number of these frac- 
tures may be reasonably expected to reach a favorable termination, a 
much larger proportion than usual of fractures of the shaft at other 
points are to be considered as very grave accidents, and in some cases as 
demanding immediate amputation. This increased gravity is due, in 
certain examples, to the greater violence required to cause the fracture ; 
in others, to the penetration of the joint by the upper fragment, and in 
all cases the hazard may be considered increased by the proximity of the 
fracture to the joint ; the thinness of the soft coverings renders them 
more liable to be made compound by the penetration of the skin by the 
upper fragment; and, finally, there exists the danger that this fragment 
will penetrate the tendon of the quadriceps, or its tendinous expansions 
on either side, and become button-holed, thus interposing a portion of 
this dense fibrous tissue between the fragments, and preventing bony 
union, as happened in two of the cases already recorded. 

If the direction of the fracture is from before upwards and backwards, 
as happens only very rarely, there is danger of the fragments pressing 
upon the popliteal artery, vein, and nerves, and causing a secondary 
haemorrhage, or gangrene of the leg, as happened with the boy Aiken. 

The treatment of the accident has already been discussed in connec- 
tion with fractures of the shaft in general ; and the conclusion would 
seem to be that, except in the last-named and exceptional fracture, as a 
rule, the straight position with moderate extension affords the most com- 
fort to the patient, and insures the best results. No doubt there will be 
cases in which Hodgen's swing, or some other forms of the flexed position, 
will 1)0 found the most comfortable, and give equally good results ; espe- 
cially when the parts about the knee are much swollen, or the knee-joint 
itself has been penetrated. It will be noticed, however, that in the few 
cases in which this position was adopted by myself and others, a change 
had to be soon made. 

The most serious question is, perhaps, What shall be the course to be 
pursued when the bone becomes button-holed in the tendon, without 
penetrating the skin ? In neither of the two cases seen by me could the 
fragment be withdrawn from the tendon by flexion or extension, even 
when the patient was under the influence of the anaesthetic. Will it be. 



FRACTURES OF THE CONDYLES. 523 

proper, then, to cut through the skin, expose and remove the projecting 
bone, and then reduce it ? In one of my cases this was not done, and 
although the union was very long delayed, it is reported to have been 
finally accomplished ; but of the correctness of this report I do not feel 
assured. In the other case I resected the bone, and my patient died. I 
confess that I do not think I would be inclined to repeat the operation, 
but that I would prefer to submit my patient to the risks of non-union, 
or of a fibrous union. Upon this subject, so far as I know, surgeons 
have furnished hitherto no experience, and have given no opinions ; nor 
indeed am I aware that they have made any allusion to this class of 
cases. It is a matter, therefore, for future study. 

Bryant says that he has once cut the tendo Achillis in a case of frac- 
ture at the base of the condyles, and he recommends it in all cases. 1 I 
cannot agree with Mr. Bryant as to its necessity or utility ordinarily, 
since I do not think that the lower fragment has that tendency to tilt 
backwards, which, in Mr. Bryant's opinion, renders a paralysis of the 
gastrocnemius necessary. This point has been discussed elsewhere in 
this chapter. 

It has been already mentioned that Dr. M. A. Morris, of Harvard, 
Charlestown. Mass., has repeated Mr. Bryant's operation in a case in 
which the fracture was through the base and between the condyles at the 
same time. In this case the operation proved very serviceable. 2 

§ 6. Fractures of the Condyles. 
(a) Fractures of the External Condyle. 

Dr. Alph. B. Crosby, 3 of New Hampshire, has published an account 
of a case of simple fracture of the external condyle, in a young man 
twenty-one years of age, and which happened from a sudden twist of the 
limb, while he was undressing himself to bathe. He was "standing on a 
shelving bank, with the right leg flexed over the left in order to remove 
his pantaloons ; he lost his balance, partially twisted the leg, and fell to 
the ground." Six months after, the fragment was removed by Dr. 
Crosby, through an incision, below the condyle. The recovery of the 
young man has been complete. 

The accompanying drawing represents the specimen as seen from its 
lower or cartilaginous surface, and of its actual size. (Fig. 203.) 

John O'Neill, aBt. 40. fell down stairs in Dec. 1873, bending his left 
leg under his body, and fracturing the external condyle. About three 
months later the patient was brought under my notice by Dr. Stanley. 
The patient was able to walk with a slight halt; the fragment, appar- 
ently about one inch in diameter, moving upwards about half an inch 
when the leg was flexed, with a distinct and painful crepitus. When at 
rest, the fragment formed a marked projection. It is not certain whether 
the line of fracture entered the joint. 

I examined the limb severa] times during the succeeding two years, 

1 Bryant. Loud, ed., I^Tl'. p. 986. 

2 Morris, Med. Rec., March, 1*:*, from Boat. Med. and Surg. Journ., Nov. L877. 

3 Crosby. New Hampshire Journ. of Med., 1857. 



524 



FRACTURES OF THE FEMUR. 



and found the condition of matters unchanged, except that the usefulness 
of the limb has steadily improved. Bandages and knee-supports have 
served no useful purpose, and have been laid aside. 

Dr. T. S. Kirkbride has also reported an example of simple fracture 
of this condyle, which was produced by the kick of a horse, the blow 
having been received upon the inside of the knee. When this patient 
entered the Pennsylvania Hospital, Dec. 1834, the knee was much 
swollen, and crepitus was plainly felt, but the fragment was not dis- 
placed ; the muscles upon the outer side, however, were so strongly con- 
tracted as to abduct the leg, and produce considerable angular deformity. 



Fig. 203. 



Fig. 204. 





Dr. Crosby's specimen of fracture of 
the external condyle. 



Sir Astley Cooper's case of fracture of 
the external condyle. 



The limb could be easily made straight, but it returned to its former 
position of abduction as soon as it was released. When fully extended, 
slight bending of the joint did not give severe pain ; but when in any 
degree flexed, all motion was very painful. ' 

The limb was placed in a long straight fracture-box, and cold applica- 
tions were made ; great swelling followed. It was kept extended in this 
manner, or in the long splint of Desault, twenty-eight days ; at which 
time union seemed to have taken place, but the motions at the joint were 
very limited, and productive of great pain. From this period the limb 
was laid in a splint, so constructed as that the angle of the knee could 
be changed daily. At the end of about six weeks he began to walk on 
crutches, and he could then flex the leg to a right angle. 1 

Sir Astley Cooper has related a case of compound fracture of the same 
condyle, produced by falling from a curbstone upon the knees. The 
man died on the twenty-fourth day. On examination after death, the 
external condyle was found to be broken off, and also a considerable 
fragment was detached from the shaft higher up. 2 (Fig. 204.) 

1 Kirkbride, Amer. Journ. Med. Sci., May, 1835, vol. xvi. p. 32. 
'-' Sir Astley Cooper, on Disloc., op. cit, p. 239. 



FRACTURES OF THE CONDYLES. 525 



(b) Fractures of the Internal Condyle. 

Dr. Thomas Wells, of Columbia, S. C, has reported an example of 
fracture of the internal condyle, accompanied with a dislocation of the 
head of the tibia outwards and backwards. The man was about forty 
years old, and intemperate. Dr. "Wells was not called until two days 
after the injury was received, when he found the limb greatly swollen 
and gangrenous. The man's account of himself was that while walking 
in the back yard he fell, and thus dislocated his knee, and that he was 
then brought into the house, being unable to stand upon his feet. It 
does not appear that any attempt was made to reduce the limb, probably 
because his general condition indicated that speedy death was inevitable. 
On the fourth day he died. The autopsy disclosed, in addition to the 
dislocation of the tibia, that a thick scale of bone was broken from the 
inner part of the inner condyle, but it remained attached to the liga- 
ments. 1 

A case reported to me by Dr. Lewis Riggs, a very intelligent surgeon, 
practising in Homer, Oneida Co.. X. Y., was more successful : 

A lad, aet. 15, was kicked by a horse, the blow being received upon 
the right knee. Dr. Riggs saw him within three hours after the acci- 
dent, and found the internal condyle of the right femur broken off, 
carrying away more than half the articulating surface of the joint ; the 
tibia and fibula were at the same time dislocated inwards and upwards, 
carrying with them the broken condyle and the patella. The displace- 
ment upwards was about two inches, and the sharp point of the inner 
fragment had nearly penetrated the skin. There was no external wound. 
The knee presented a very extraordinary appearance, and the lad w T as 
suffering greatly. Being at a distance from town, and the Doctor having 
no chloroform or- pulleys with him, he was obliged to depend solely upon 
the aid of five men who were present. The first attempt at reduction 
was unsuccessful ; but in the second attempt, when the men were nearly 
exhausted in their efforts at extension and counter-extension, and while 
the Doctor was pressing forcibly with both hands upon the two condyles, 
the bones suddenly came into position, except that the breadth of the 
knee seemed to be slightly greater than the other, a circumstance which 
waa probably due to the irregularities of the broken surfaces, which pre- 
vented perfect coaptation. 

Neither splints nor bandages were required to maintain the bones in 
place ; but anticipating the probable occurrence of anchylosis, and with 
a view to making "the limb as useful as possible in this condition," he 
was placed upon "a double-inclined plane," which, being supplied with 
lateral supports, would also prevent any deflection in either direction, in 
the limb was disposed to such displacement. 

The subsequent treatment consisted in the use of cold water-dressings. 
Very little inflammation followed. A portion of the integument sloughed, 
but the bone was not exposed, and it healed rapidly. On the twenty- 
fourth day Dr. RiggS gave to the joint passive motion, and this was 

1 Wells, Amer. Joorn. Med. Set, May. 1882, vol. x. p. 25. 



526 



FRACTURES OF THE FEMUR. 



Fig. 205. 



repeated at intervals until, at the end of three months, he was able to 
walk with a cane. At the end of a year Dr. Riggs examined the leg, 
and found the knee a very little larger than the other, and he could not 
flex it quite as completely. In all other respects it was perfect, and the 
boy himself declared it was as good as the other. 

The Dupuytren museum contains a specimen illustrating this fracture, 
which was presented to the museum by Verneuil, and is referred to by 
Trelat. 1 The fragment was not displaced. 

Treatment of Fractures of either Condyle. — The few cases of these 
accidents which I have seen reported have been, with one or two excep- 
tions, treated in the straight position. In Kirk- 
bride's case any degree of flexion was painful, 
although there was little or no displacement of the 
fragment ; and we think we can see, in the relative 
position of the articular surfaces of the tibia and 
femur, a sufficient reason why the straight or nearly 
straight position must generally be preferred. 
Whichever condyle is broken, the remaining con- 
dyle will be sufficient to prevent a dislocation and 
consequent shortening of the limb, unless, indeed, 
JBJ \ the dislocation has already occurred as an imme- 

jB diate consequence of the injury. It is very certain 

that it would not take place from the action of 
the muscles when the limb was straight. In the 
flexed position I can conceive that it might take 
place, but yet not easily. It is not a dislocation 
of the limb, then, that we seek chiefly to avoid, but 
a deflection of the leg to the right or to the left, 
according as one or the other of the condyles has 
been broken. It will be readily seen that, in order 
to resist this tendency, nothing but the straight 
position will answer, and that for this purpose it will be necessary to lay 
a long splint upon one or both sides of the limb, and to secure the whole 
length of both thigh and leg to this splint. The long fracture-box used 
by Kirkbride, if well cushioned on all sides, seems to me at once to 
answer most completely this important indication, rendering it even un- 
necessary to employ a bandage, since the opposite sides of the box will 
compel the limb to adopt the proper position. 

As to the remainder of the treatment, it must consist essentially in 
the employment of such means as are calculated to prevent and allay 
inflammation. 

As soon as the union is consummated the joint surfaces should be sub- 
mitted cautiously to passive motion, in order to prevent anchylosis ; and 
it would be better to commence this so early as to hazard somewhat a 
displacement of the fragment, rather than to wait too long. It may not, 
in some cases, be improper as early as the fourteenth day, and in nearly 
all cases it should be practised as early as the twenty-eighth. Of course, 




Fracture of the inter- 
nal condyle. (Verneuil's 
case.) 



Verneuil, Trelat, Arch. Gen. de Med., 1854, t. 2, p. 78. 



FEACTURES OF THE CONDYLES. 527 

the presence of active inflammation in the joint would render motion 
improper. 

(c) Fractures between the Condyles and across the Base. 

Etiology. — A fracture of this character may be produced by a blow 
received directly upon any point of the lower extremity of the femur : 
sometimes the blow has been received upon the patella when the knee 
was bent, and Bichat mentions a case in which it was produced by a 
fall upon the feet. 

Symptoms. — This fracture is easily distinguished from the preceding 
by the much greater mobility of the fragments and by the palpable short- 
ening of the limb, since an overlapping of the broken end is here almost 
inevitable. Each fragment may be felt to move separately, and the 
motion will be accompanied with crepitus. 

Prognosis. — The danger of violent inflammation in the joint is im- 
minent, and anchylosis of the knee is to be anticipated as the most favor- 
able result, since the joint surfaces are likely to be rendered immovable 
by fibrinous deposits in their immediate vicinity, and also by the adhe- 
sion of the muscles to one another and to the bone higher up, at the point 
where the fracture of the shaft has occurred. More fortunate results than 
these may. indeed, be hoped for, inasmuch as they have occasional ly been 
noticed, but they cannot fairly be expected. 

In a majority of cases such accidents have demanded, either immedi- 
ately or at a later period, amputation. If recovery takes place, a short- 
ening of the thigh is inevitable. Mr. Canton, of London, has twice 
performed successfully resection of the joint end of the bone in such 
accidents. 1 

Treatment. — Malgaigne saw a patient who had been treated by Ghier- 
bois. with the aid of extension and counter-extension, who was confined 
to his bed five months, and who had at the end of eight years very little 
motion in the joint, and he seems disposed to charge in some measure 
these unfortunate consequences to the position in which the limb was 
placed, namely, the straight position. But, in my opinion, it is much 
more reasonable to suppose that, if the treatment was at all responsible 
for the results, the error consisted in too long and unnecessary confine- 
ment, and in too much extension. I suspect that the mere matter of 
position had nothing to do with the anchylosis. Malgaigne does not, 
however, himself recommend anything more than a very slight amount 
of flexion at the knee; and to this practice I am prepared to give my 
assent ; since it will give to the limb a useful position in case anchylosis 
iccur, and it is not inconsistent with the employment of the mod- 
erate amount of extension which alone is justifiable after this accident. 
If the young Burgeon should differ with me in opinion as to the necessity 
or propriety of using great force to retain the fragments in place and 
prevent overlapping. I beg him to consider that this fracture probably 
never happens except from the application of an extraordinary force, 
and that consequently intense inflammation and swelling are almost 

1 Canton. Laneel 1868. Trans. London Path. Soc, 1860. 



528 FRACTURES OF THE FEMUR. 

certain to ensue ; and that in some cases, the very fact that immediately 
after the accident, or for. some hours succeeding, no swelling occurs, or 
muscular contraction, and that replacement of the fragments is easily 
accomplished, is evidence only of the great severity of the injury, and 
that the whole system is prostrated by the shock ; to which, if the patient 
does not succumb, sooner or later reaction will ensue, and the fragments 
will be gradually drawn up with a resistless power. The surgeon ought 
to remember also that to make extension in this case, he is obliged to 
pull upon those very ligaments and tendons about the joint which, having 
been torn or bruised, must soon become exquisitely sensitive. 

The long straight box, already recommended when speaking of frac- 
ture of one condyle, is equally applicable here ; only that it needs a foot- 
board, or some sort of foot-piece to which an extending apparatus may 
be secured, and that a pillow should be placed under the knee to give the 
limb the proper flexion. 

Case. — A man was admitted into St. Thomas's Hospital, London, 
Sept. 17, 1816, with a fracture between the condyles, accompanied also 
with a fracture through the shaft higher up, occasioned by being caught 
in the wheels of a carriage while in motion. There was a small wound 
opposite the point of fracture, and the external condyle was displaced 
outwards. 

The limb was laid in a fracture-box, and in a position of semiflexion. 

On the 18th of November, the external condyle, having protruded 
through the skin, and being dead, was removed with the forceps, bring- 
ing with it a portion of the articular surface. 

On the 6th of December he was discharged from the hospital, and in 
February following he was walking without any support, and with the 
free use of the joint. 1 

Case. — A gentleman living about eighty miles from town was thrown 
from his carriage, breaking the left femur just above the condyles into 
many fragments, so that when I saw him on the following day the 
attending physician showed me about four or five inches of the entire 
thickness of the shaft which he had removed. The external condyle was 
completely separated from the internal, and was quite movable. 

In this case the attempt to save the limb resulted in the loss of the 
patient's life on the sixth or seventh day. 

In a case of this kind, Dr. Morris, of Charlestown, cut the tendo 
Achillis with an excellent result. 2 

(d) Separation of the Lower Epiphysis. 

M. Coural 3 relates the case of a boy eleven years old, who, while his 
leg was buried in a hole up to his knee, fell forwards, separating the 
lower epiphysis from the shaft, and at the same time driving the shaft 
behind the condyles into the popliteal space. The epiphysis also became 
tilted in such a manner that its lower extremity was directed forwards. 
The limb was amputated. 

1 Sir A. Cooper on Disloc, etc., op. cit., p. 239. 

2 Morris, Boston Med. and Surg. Journ., Nov. 1877. 

3 Coural, Arch. Gen. de Med., vol. 9, 1825, p. 337. 



SEPARATION OF THE LOWER EPIPHYSIS. 529 

Madame Lachapelle mentions a case in which traction at the foot of a 
child in the act of birth, caused at the same time a separation of the 
lower epiphysis of the femur and the upper epiphysis of the tibia. The 
child was born dead. 1 

Dr. Davis Halderman. 2 of Columbus, Ohio, Professor of Surgery in 
the Starling Medical College, reports a case in a boy, 18 years old, 
caused by a violent blow upon the front and lower part of the thigh. 
The limb was shortened two inches. It was found impossible to reduce 
the fracture, even under the influence of ether. Gangrene ensued, and 
on the fifth day the limb was amputated. On examination it was ascer- 
tained that the epiphysis was separated completely, and carried back- 
wards by the action of the popliteus and gastrocnemius ; the popliteal 
artery and vein, and the internal popliteal nerve were displaced forwards, 
lying between the upper and lower fragments, and were much contused. 
The epiphysis was lodged above the internal condyle in such a way that 
it would have been impossible to displace it by traction. 

Dr. Little presented to the Xew York Pathological Society, May 24, 
1865. a specimen obtained from his own practice. A boy, aet. 11, while 
hanging on the back of a wagon, had his right leg caught between the 
spokes of the wheel which was in rapid motion. A few hours after 
the accident. Dr. Little found the upper fragment of the femur projecting 
through an opening in the upper and outer part of the popliteal space. 
On examination, the wound did not appear to communicate with the 
knee-joint. Under the influence of an anaesthetic the fragments were 
reduced : the reduction occasioning a dull cartilaginous crepitus. There 
was at the time no pulsation in the posterior tibial artery, and the limb 
was cold. The limb was laid over a double-inclined plane. The follow- 
ing day the upper fragment was again displaced, and it was found that it 
could only be kept in place by extreme flexion of the leg. This position 
was therefore adopted and maintained ; considerable traumatic fever fol- 
lowed, with swelling, and on the thirteenth day a secondary haemorrhage 
occurred from the anterior tibial artery near its origin, and it became 
necessary to amputate. The boy made a good recovery. The specimen 
showed that the line of separation had not followed the cartilage 
throughout, but had at one point traversed the bony structure. 

Dr. Voss, at the same meeting, remarked that he had met with the same 
accident. There was no protrusion of bone, but an abscess formed, and 
it became necessary to amputate. 

Dr. Buck saw a case which occurred in the practice of Dr. Hugh 
Walsh, of Fordham. The subject was a boy 14 years old, and it hap- 
pened in the same manner as with Dr. Little's patient. 3 

Tapret and Chenet 4 have reported a similar example caused in the 
same manner, in a boy 9 years old. The integuments were lacerated 
and there was considerable haemorrhage. The limb was dressed with 
plaster of Paris, but after a few days gangrene ensued in the region of the 
part- wounded, and it became necessary to amputate. On examination 

: Mad. Lachapelle, Prat, dee Accoucb., t. 2. p. 225, and t. 3, p. 180. 

2 Halderrnan, Med. Rec. July 8, 1882, p. 800. 

3 Little, V " V. Journ. Med., Nov. 1866. 

* Tapret and Chenet, Bull. Soc. Anat. de Paris 1876, p. 25. 



5o0 FRACTURES OF THE FEMUR. 

it was found that the fracture, commencing externally, followed the line of 
union between the epiphyseal cartilage and the shaft, but toward the 
inner side it deviated a little, so as to include a small portion of the 
diaphysis. 

The same accident has been frequently caused by attempts to straighten 
the limb in cases of anchylosis in children. Chauvel 1 saw a case in which, 
the separation having been produced in this manner, suppuration ensued, 
and the patient died of pyaemia. Yolkmann 2 says that he has three 
times detached the epiphysis by rotating the thigh while seeking for 
crepitus in patients suffering with hip-joint disease, or by the traction 
made while applying a plaster-of-Paris dressing. 

Wm. Smallwood, set. 12, Aug. 11, 1877, had his right leg caught in 
the spokes of a wagon-wheel, breaking his thigh at the junction of the 
lower epiphysis with the diaphysis, the lower end of the upper fragment 
protruding five inches through the flesh. The end was nearly square. 
His father, Dr. S. B. Smallwood, of Astoria, N. Y., the lad being under 
the influence of ether, reduced it within one hour by violent extension 
and flexion of the leg over his knee, one finger being in the wound, and 
adjusting the fragments. Lateral splints were employed. The wound 
closed in about nine months, and in the meanwhile two small fragments 
of bone escaped. He had also a sharp attack of synovitis. 

I examined him April 18, 1880, and found the leg straight, but short- 
ened three-quarters of an inch. There is complete anchylosis of the 
knee-joint, but the muscles of the leg are well developed, and he walks 
with very little limp. 

§ 7. Non-union and Delayed Union of Fractures of the Shaft of the 

Femur. 

Examples of delayed and of non-union of the shaft of the femur are 
not very infrequent, yet I must be permitted to say that complete failure 
to unite by bone has never occurred in my practice when I have had 
charge of the patient throughout ; and I cannot but think that in some 
of the cases which have come under my notice the mode of treatment 
was responsible for this unfortunate result. The fragments have not 
been properly supported, or there has been allowed too much freedom of 
motion. In other cases, no doubt, the cause of delay was some of those 
conditions of the patient or of the fracture which have been explained in 
the general chapter on delayed and non-union. 

The treatment of these cases demands a brief consideration, and espe- 
cially does it seem necessary to call attention to the danger of resorting 
to some of those surgical expedients which may be employed with much 
hope of success, and without any danger to the life of the patient in the 
case of other long bones. 

A strong conviction has forced itself upon me that it is never proper, 
in the case of this bone, to resort to either resection and the wiring of 
the bones together, or to a seton, or to other means of establishing any 
considerable continuous or permanent irritation, with the view of exciting 

1 Chauvel, Diet. Encyc., Art. Cuisse, p. 233. 

2 Volkmann, Virchow's Jahresb., 1866, 2, p. 337. 



NON-UNION AXD DELAYED UNION. 531 

the tissues to the deposit of bony callus. The feraur lies too deeply im- 
bedded in a mass of muscular and tendinous tissue to make it safe or 
prudent to excite suppurative action in the neighborhood of the bone, 
even if the drainage were the most perfect ; and both of these methods, 
thoroughly carried out, insure suppuration. To this danger these 
methods have to add the necessity, during a long period of time, of 
confining the patient in splints and in bed ; while in the case of all the 
other long bones — even in the case of the leg, but especially of the 
upper extremities — it is possible to permit the patient to go about, and 
thus to retain his general health — a condition most essential to the 
process of repair. 

In the very complete and valuable tables constructed by Dr. Frank 
Muhlenberg, compiled from various medical journals, of ununited fractures 
— published by Dr. Agnew in his Principles and Practice of Surgery — 
of 155 cases of ununited fracture of the femur there were 92 cures, 3 par- 
tial cures, 47 failures, 12 deaths, and 1 of which the result is unknown. 
Of this number resection was practised in 32 cases ; and while 19 were 
said to have been cured, 8 died. 1 This is certainly an alarming mor- 
tality, but the presumption is that the proportion of fatal cases is actually 
very much larger than these tables would indicate, since fatal cases are 
much less likely to find their way into the journals than successful cases: 
and I will add that Dr. Agnew himself, a surgeon of large experience and 
acute observation, has declared without reserve that both resection and 
the seton ought to be condemned in the treatment of ununited fracture 
of the thigh. 

It has happened to me to hear of two cases of resection made by ex- 
cellent surgeons of my acquaintance. In one case the patient died, and 
in the other, although he escaped death, there was no union of the frag- 
ments. 

I have never used a seton, nor has any other surgeon within my per- 
sonal acquaintance, but its dangers are easily understood by the practical 
surgeon; and one or two cases in which other modes of operating have 
within my knowledge accidentally resulted in suppuration, will sufficiently 
illustrate the danger of inducing suppurative action in these tissues. 

Within a year one of the surgeons of a New York city hospital, I am 
informed, in attempting to perforate the fragments with a Brainard's 
perforator, broke the instrument. Suppuration ensued, and the patient 
died. For the following fatal result I am myself responsible : 

Frank Pavesco, an Italian rag-picker, aged about forty years, was ad- 
mitted to Bellevue, March 18, 1877, with a fracture of the left femur in 
the middle third, caused by a fall upon the sidewalk. I found him in 
my wards nearly six weeks later, when I went on duty. There was at 
that time no union of the fragments. At the end of eight weeks (May 
17; I perforated the fragments, and twisted the limb forcibly, and then 
secured the leg and thigh in plaster. On the 19th two shawl-pins were 
introduced to the bone, and left in place twenty-four hours. This was 
repeated on alternate days ; but on the 23d, finding that very little or no 

1 Principles and Practice of Surgery, bv D. Haves Agnew, M.D., LL.D., vol. i. 
p. 806. 



532 FRACTURES OF THE FEMUR. 

inflammatory action had been awakened, I penetrated the fragments with 
a gimlet, and thus fastened them together, intending to remove it in time 
to avoid all danger of suppuration. This was not done, the gimlet re- 
maining in place several days, and until pus had formed. A counter- 
opening was made, and means employed to secure complete drainage. It 
being apparent that the danger would not now be diminished by removing 
the gimlet, it was permitted to remain four weeks, during which time it 
held the fragments firmly together; but my patient gradually sank, and 
died on the 25th of August. 

The strictly surgical expedients which are most likely to prove suc- 
cessful in cases of simply delayed union, and which sometimes have 
proved successful in cases of non-union, after the lapse of months or 
years, are violent twisting of the limb and perforation ; the perforation 
being made thoroughly through the ends of the fragments, at several 
points, and repeated from time to time, while the limb is at rest and in- 
closed in splints. 

In Muhlenberg's table of cases published by Agnew, already referred 
to, there are 17 cases treated by "manual friction," of which 7 were 
cured, 10 failed, and none died. Of 18 cases treated by " drilling with 
its modification," 9 were cured, 8 failed, and 1 died. 

In the following case I succeeded by manual frictions, drilling, per- 
foration, and mechanical apparatus combined, or successively employed : 

Wm. F. J., get. 35, of Jetersville, Amelia Co., Va., broke his left 
thigh a little above its middle, Aug. 9, 1876, by a fall from a ladder. 
Mr. J. was a lawyer by profession, but accustomed to exercise, and in 
perfect health. He was treated with a straight splint and perineal band, 
which latter, he thinks, drew the upper fragment out of line. 

About nine months after the accident he came to New York and con- 
sulted me. I found the fragments united only by ligament ; the femur 
bent outwards at the point of fracture, and shortened two and a half 
inches. 

May 1, 1877, my patient being anaesthetized, I perforated the frag- 
ments in various directions with Brainard's instrument, then bent the 
limb violently, and applied splints. On the 7th I opened and tightened 
the dressings. The following day I pushed an ordinary shawl-pin down 
to and between the fragments, leaving it in place twenty-four hours. 
On the 10th of May I again introduced a shawl-pin and left it in seven 
days, causing a slight suppuration near the skin. This was repeated on 
the 23d, and ic was allowed to remain again seven days. I think this 
was repeated once or twice more. July 12th, bored through both frag- 
ments with a gimlet, and left it in forty-eight hours. Aug. 7th, I again 
used the perforator very thoroughly, and left it in forty-eight hours. 

Under my instructions, Mr. Stollman then constructed for him an 
artificial support for his thigh and leg. On the 17th of August the 
motion between the fragments was so slight that Mr. J. thought bony 
union had occurred, but it had not ; the fibrous union, however, was very 
close and firm. Having returned to his home in Virginia on the 25th of 
August, and continuing for some time to wear the apparatus, he wrote 
me, under date of November 1, 1878, that the fragments were now firmly 
united by bone — a period of six months since the treatment was com- 



NON-UNION AND DELAYED UNION. 533 

nieneed. Several letters received since inform me that he walks long 
distances without a cane or other means of support, and that the consoli- 
dation is complete. 

In another similar case, that of Charles C. Campbell, of Alta, 111., I 
have not thus far been equally successful. Campbell, 22 years old, was 
crushed under a log, and held in this position for some time, Jan. 27, 
1879. fracturing the right thigh in the upper part of the lower third. 
The fracture was treated with Buck's extension, but without the long 
side-splint to secure quietude of the body. Extension was continued 
eight weeks, when, as no union had taken place, a starch bandage was 
applied, and he was permitted to go about on crutches. About the 15th 
of October the fragments were perforated, and on the 1st of November 
this was repeated, with twisting of the limb ; splints were applied, and 
he remained in bed ten weeks. 

When he consulted me in February, 1880, the limb was shortened 
two inches and one-quarter, and was not united. On the 15th I placed 
him under the influence of ether, perforated the fragments very thor- 
oughly in various directions, and then wrenched the limb forcibly. 
Splints and extension were applied. The perforation was repeated 
often, as in the case of Mr. Jackson, but, at the end of eight weeks, 
there was not the slightest attempt at union. A thigh and leg support 
was made and applied by Messrs. Tiemann and Stollman, and he went 
home. 

After the first operation was made I discovered that his gums were 
spongy and ulcerated, presenting the appearance usually seen in scor- 
butus. He informed me that this condition existed before the first 
fracture occurred. 

I have twice seen the same measures fail in the hands of other sur- 
geons. 

As to the value of mechanical supports, which permit the patient to 
go about with or without crutches, there can be no doubt ; yet the re- 
ported successes of this method are not very numerous, at least in the 
case of old ununited fractures of the femur. 

Muhlenberg, in his tables, reports 29 cases treated by mechanical 
appliances alone, of which 22 were cured. 2 were relieved, 4 failed, and 
1 died. Probably some of these were recent cases. 

I have mentioned the case of Mr. Jackson, in whom I succeeded by 
mechanical appliances after operative procedures. 

Miles Fan-, aet. 4.",. had bis right thigh broken by a direct blow near 
it- middle, Fob. 7. 1866. It was treated in the extended position with 
tit's apparatus, and did not unite. Dr. Thaddeus P. Seelye, of 
Chicago, operated by perforation, Sept. 29, 1867, but with no success. 
I visited him at bis home in St. Lawrence Co., X. Y., Sept. 3, 1868, 
and repeated the operation by perforation, twisting and friction of the 
fragments, applying splints, etc. I left the patient in charge of* a phy- 
ear, and do not consider myself responsible for the subse- 
quent management. Bony union did not occur, and some time later he 
came to the city, and Dr. Budson made for him an artificial support at 
my request. After several months there was no bony union, and I 
presume none has occurred since, but I am not able to burn t!i<- facts. 



534 FRACTURES OF THE PATELLA. 

0. S. Budlong, ;\?t. 55, of Utica, had a fracture of the left femur four 
inches above the knee, caused by a direct blow, Nov. 10, 1875. His 
surgeon is confident the bone was comminuted. Splints were applied 
after extension had been made under ether. 

I found the limb, Sept. 18, 1876, shortened two and a half inches, 
and not united. At my request, an artificial support was applied by 
Dr. Hudson, and he returned home. A letter received Oct. 3, 1877, 
says "the bone has not united, but the apparatus has been of the greatest 
comfort to him, as it enables him to walk." May 15, 1878, it had not 
vet united. 



CHAPTER XXX. 

FEACTUEES OF THE PATELLA. 

Ix 1880, I made a careful study of 127 cases of fracture of the 
patella. Of these, 71 were either treated by me, or they were seen by 
me in consultation in the course of the treatment, or came subsequently 
under my notice. Of nearly all of these I made careful notes at the 
time. The remainder of the 127 cases (56) are copied from the Belle- 
vue Hospital records, including all that had been recorded up to the date 
of the completion of the study ; excluding only those which had been 
treated by myself, and were included, therefore, in the class of cases first 
mentioned. The cases, reported at length, as copied from the records, 
have been published, with the conclusions drawn from them, and are 
now embodied in a single volume for the instruction of the profession. 1 

In this chapter I shall make free use of the observations and state- 
ments contained in that volume, without, however, attempting to describe 
in detail the cases, but presenting here only a summary of them. 

Total number of cases. — 127. 

fee.— Males, 99; females. 2s. 

Age. — Ten years and under, one case. This is the case (52) of a lad 
five years old, in whom, from a direct blow, a small piece of the margin 
of the patella was broken off. 

From ten years, including twenty, six cases ; of which 1 (113) was 
1<J years old — a boy — the fracture being oblique and caused by a direct 
blow : 1 (case 19) was 19 years old — the fracture was transverse, and 
was caused apparently by a direct blow. In this case the ligament sub- 
sequently gave way completely on the outside, and a new patella formed 
in the very much elongated ligament on the inner side. The remaining 
four cases were at the age of 20 years: all were transverse; two are 
known to have been caused by muscular action — one by direct force, and 
in one the cause is not stated. 

Before the twentieth year of life, then, there were only three fractures, 
and these were all supposed to be caused by direct blows. Up to this 

1 Fracture of the Patella. A Study of 127 Cases, by Frank H. Hamilton, M.D. 
Xew York, Chas. L. Bermingham «fc Co., Med. Publishers, 1880. 



FRACTURES OF THE PATELLA. 535 

period, muscular action seems to take little or no part in the production 
of these fractures. 

From twenty years, including thirty, 48 cases. From thirty years, 
including forty. 33 cases. From forty years, including fifty, 22 cases. 
From fifty years, including sixty, 8 cases. From sixty years, including 
seventy, 4 cases. From seventy years, including eighty, 1 case. In this 
one case, the patient, a woman, was 80 years old. 

In all the six cases included in the last two decades — that is, from sixty 
years, including eighty, four are known to have been caused by direct 
blows, and the remaining case, Bridget Callaghan, 80 years old, fell fif- 
teen feet, and it is fair to presume that the fracture was caused by a 
direct blow. 

It would seem, then, that after the sixtieth year, muscular action alone 
seldom causes these fractures, the largest number of cases having occurred 
between the twentieth and fortieth years of life ; the total in these periods 
being 103, out of 122 whose ages are known, or, if we include the three 
at the twentieth year, 106 out of 122 cases. 

Right or Left Limb. — Of 134 in which this fact is recorded, ninety- 
three were in the left limb, and forty-one in the right. 

Character of the Fractured — Of the whole number, all were simple, 
except eleven ; and of these, nine were comminuted, and two were both 
compound and comminuted. Of the comminuted fractures, cases 61 and 
94 were accompanied with fractures of the thigh also — one died of shock 
on the fourth day, and one died after amputation, rendered necessary by 
gangrene. 

Direction of the Fracture. — The fractures were transverse in 106 
cases — not including two which were transverse and vertical (commi- 
nuted) — of these 106 cases, twenty-two are recorded as below the middle 
of the patella, sixteen at the middle, and seven above the middle. 

Cause of the Fracture. — Twenty-five are known to have been the result 
of muscular force alone ; and fifty-eight are recorded as having received 
blows upon, or as having fallen upon the patella, and have been placed 
in the list of those caused by direct blows. In forty-three cases nothing 
is said as to the cause. 

Of the transverse fractures, it will be noticed that a majority of those 
occurring below the middle are ascribed to muscular action — that is, 
twelve out of twenty in which the cause is given. Of four oblique frac- 
tures, three are known to have been from direct force ; and all of the 
comminuted fractures, except case 127, were from direct blows, as were 
also the two compound fractures. 

Active Synovitis <<n<l Bursitis. — I infer that active synovitis ensued 
in at least thirty-four cases, and probably in many others. Inflamma- 
tion of the bursa of the patella is mentioned once. Probably in most 
- the bursa is torn open as the patella ascends, and communicates 
freely with the joint, so that bursitis could not be recognized as a distinct 
phenomenon. 

Blood in the Joint, etc. — In case 90, a compound fracture, the pres- 
ence of blood in the joinl was actually demonstrated. Probably it was 
present in many other cases, but the fact could not be proven. Pretty 



536 FRACTURES OF THE PATELLA. 

extensive subcutaneous eeclnjmoses on the sides of the knee and in the 
ham were very frequently observed. 

Treatment. — It will be impossible to summarize the treatment. Nearly- 
all of the recognized plans of treatment were adopted, but in a majority 
of cases the same plan of treatment was not continued from the begin- 
ning to the close ; and it would be difficult in most cases to say to which 
particular method the result must be ascribed. Of the specific forms of 
apparatus, there are mentioned Lausdale's, Wyeth's, Turner's, Mott's, 
Malgaigne's hooks, Sir Astley Cooper's, both of my own methods, plas- 
ter of Paris, and other forms of immovable dressings, the " lock strap," 
" wooden fingers," pulley and weight, crescentic pads, and figure-of-8 
bandages, also elastic bands, rollers, etc. Most of the patients have 
been kept in the recumbent posture, with the foot elevated ; but some 
have been allowed to walk about on crutches, especially when either of 
the forms of immovable apparatus has been employed. 

Results. — We now approach one of the most important parts of our 
subject, and, fortunately, the records are sufficiently accurate and full 
here to enable us to make valuable conclusions. 

It is stated distinctly in 84 cases that the union was fibrous. The bond 
of union did not permit the fragments to be moved upon each other soon 
after the treatment was concluded, and therefore may be constituted of 
bone, in case 11, and I believe in three or four other cases. 

In cases 22, 23, and 64 no union ever occurred. 

The length of the bond of union is given as J of an inch in 16 cases ; 
J in 33 cases ; f in 13 cases ; 1 inch in 3 cases ; 1J in 2 cases ; 2 in 3 
cases ; 3 J in 1 case ; 4 in 1 case, and 5 in 1 case. The last four cases, 
or those in which the separation exceeds 1^ inches, are respectively 
cases 22, 23, 54, and 111. 

The above records, it will be understood, do not include cases of rup- 
ture subsequent to union, but only the results of the first treatment. 
I shall refer to the results after refracture or rupture of the bond of 
union hereafter. 

It is not to be supposed that these estimates of the length of the bond 
of union are absolutely accurate. Probably the length of the ligament 
was generally a little more than is stated, but the records are sufficiently 
accurate for our purposes. All but 8 are united with a ligament of one 
inch or less in length, and the largest number have a ligament of only 
half an inch. 

Anchylosis — more or less complete — has existed in nearly all of the 
cases when the limb was first removed from the apparatus ; being most 
complete, as a rule, in those cases in which the joint has been kept the 
longest in the dressings, without the use of passive motion. 

In no case recorded has force been resorted to to overcome this an- 
chylosis ; but it has gradually disappeared under passive and active use 
of the limb within a year or two. 

Rupture of the New Ligament. — The new ligament has given way 
more or less completely in 27 cases. Possibly we may have included in 
this number one or two which were never held well in position, such as 
cases '.' and 32, in which the inner portion of the ligament alone is elon- 
gated. This unilateral elongation occurred three times on the inner side 



FRACTURES OF THE PATELLA. 537 

and once on the outer. Of the entire number, 5 were gradual, the elon- 
gation commencing soon after the patients began to walk : and 18 oc- 
curred within ten weeks after the receipt of the original injury, generally 
on the seventh or eighth week, when the patient in his first attempt to 
walk has slipped, and the limb has been suddenly bent. After the 
eighth week there are. 4 cases at 3 months. 3 at 5 months, and 1 at 2 
years and 4 months (case 18). Case 21 is put down as refractured after 
4 years ; but the history of the case is doubtful. 

I think, in the light of this experience, it may be said that after the 
fifth month there is usually no more danger to the injured limb than to 
the sound one. 

Other Displacements of Fragments. — The lower fragment was found 
slightly tilted forwards in case 31 ; and the lower fragment overlapped 
the upper a little in case 9. The upper fragment was tilted over by the 
elongation of the inner portion of the ligament in 3 cases ; and in the 
opposite direction by the giving away of the outer portion in 1 case. In 
case 19 a new patella was formed in the much-elongated ligament. 

Repetition of the Fracture in the Opposite Leg. — Cases 6, 45, 68, 
s 5. and 124 belong to this class. Perhaps also 59 ; or it may have been 
a case of refracture. These latter accidents have evidently resulted from 
the fact that the sound limb has been compelled to receive alone the re- 
sistance in efforts to prevent a fall. 

Hypertrophy of Fragments. — This has been especially noticed in 9 
cases : namely, twice in the upper fragment alone, once in the lower, and 
six times in both. It is probable that its occurrence is much more fre- 
quent than this record implies. 

Period of Time ivhich elapsed before the Functions of the Limb were 
sufficiently restored to resume Labor. — Of the primary accidents, that 
is. of those in which there was no subsequent rupture of the union, I 
have been permitted to examine 23 cases, at periods of time ranging 
from four months to twenty-nine years. Only four of these are said to 
have acquired perfect, or nearly perfect, use of the limb in a less period 
than two years, although in general they have resumed work within 
about one year. The cause of this inability to labor has almost invari- 
ably been the lack of the necessary freedom of motion in the knee-joint 
— a partial anchylosis. 

It is remarkable, however, that in case 23, a British soldier, there 

being no union and a separation of the fragments to the extent of five 

inches, he was able to walk well at the end of twenty-nine years, when 

him. Case 22 was seen after four years with a separation of four 

incites, and case 54 was seen after seven years, and both walked badly. 

//. suits in ( '•/.<• § of Hefracture or Rupture of the Bond of Union — 
— I >f 15 cases in which the ligament gave way within a period 
of th 3 from the time of the original accident, that is, soon after 

the union bad been effected, 12 have terminated very satisfactorily. 
Under a renewal of the treatment the fragments have united with a short 
ligament. Case 56, refractured twice, and cases 40 and 47 were no! 30 
fortunate. 

I do not think that in any case where the refracture occurred later 
than this was a permanent reunion effected. 



538 FRACTURES OF THE PATELLA. 

Having given this brief analysis of these cases, I shall proceed to 
consider the subject of fractures of the patella in a more general way. 

Etiology of Fractures of the Patella. — Twenty-five of the cases re- 
ported by me are known to have been the result of muscular force alone ; 
the fractures having occurred without a fall or while the patient was 
standing, and in some cases when the knee was not bent, the fracture 
being announced by a distinctly felt snap. I believe, however, that 
muscular action was more or less efficient in causing the fracture, in all 
the simple transverse fractures, and in at least one of the comminuted 
fractures ; that is to say, in 107 of the 127 cases. 

My reasons for this opinion are: the great power of those four strong 
muscles which unite to form the tendon of the quadriceps — the fact that 
ninety-nine occurred in males — that only three occurred in persons 
under twenty years of age, and only five after the sixtieth year — the 
largest number being between the twentieth and thirtieth years of life — 
the remarkable uniformity in the direction of the fracture ; and finally 
because I am unable to cause a transverse fracture on the cadaver by a 
direct blow. I might have added also the fact, as attested by museum 
specimens, that the fracture is very uniformly from before backwards 
and downwards, as would be the case if it were caused by a cross- 
strain, the active force being attached to the upper fragment. That the 
bone breaks most often in the lower third is probably due to the fact that 
when the knee is slightly bent — and this is the position of the limb in 
which the fracture generally occurs — the centre of the patella rests upon 
the condyle of the femur, leaving the upper and lower portions unsup- 
ported, when, the lower portion, being the weakest of the two, gives way 
under the cross-strain. 

A patella having given away, transversely, to muscular action, those 
fibres of the quadriceps which are inserted into the sides of the patella 
still continuing to act, may break the bone vertically, or cause them to 
separate laterally. No doubt this is what happened in case 127. 

The source of error in estimating the value of muscular action in the 
production of this fracture has been, that in the majority of cases the 

Fig. 206. Fig. 207. 





Simple transverse fracture. Comminuted fracture. 

patients have actually fallen upon their knees, and all such cases have 
been set down as caused by direct force; but in a fall on the knee upon 
a plane surface, when the leg is flexed to a right angle with the body, 
the patella does not touch the plane ; it is only the tubercle of the tibia 
which touches, and the contact with the plane has had nothing to do with 
the fracture, except as causing, by the concussion, a more active con- 



FRACTURES OF THE PATELLA. 



539 



Fig. 208. 



traction of the muscles already rendered tense by the position and by 
the effort to prevent the fall. If a man falls headlong, with his knee 
slightly bent, the patella may strike the floor, and in this way, and by 
other methods, the patella may receive a direct blow; but even then, if 
the fracture is transverse, it is probable that the blow induced the frac- 
ture by causing a sudden spasmodic action of the muscles, for, as I have 
said before, we cannot imitate the fracture by a direct blow on the patella 
of the cadaver. 

Camper, Velpeau, Malgaigne, Tillaux, Agnew, and others have ob- 
served the frequency with which this cause has operated in the produc- 
tion of transverse fractures of the patella. Agnew speaks of a fracture of 
the patella as being frequently produced by the act of mounting a horse. 
Anatomy, Pathology, and Semeiology. — I have already stated that 
the fracture is almost uniformly transverse, occasionally oblique, and in 
a few cases the line of fracture is slightly 
curved; very seldom is the line of fracture 
vertical. The fracture occurs most often in 
the lower third, and least often in the upper 
third. In the transverse fractures the direc- 
tion of the fractures is from before backwards 
and downwards. 

In a large majority of cases the lesion is 
limited to the bone, its periosteal coverings and 
the thin and scattered fibres of the tendon of 
the quadriceps which traverse the front of the 
bone to become continuous with the ligamen- 
tum patella?. Perhaps a few of the fibres of 
the aponeurosis on either side of the patella 
give away also, but the lesion of this aponeu- 
rosis is ordinarily not extensive. For this 
reason the upper fragment seldom separates 
from the lower more than one inch, and in 
most cases only about half an inch. It is 
only when great and extraordinary muscular 
force has caused the fracture, that the aponeu- 
rosis is sufficiently torn to permit the upper 
fragment to ascend two inches or more ; and 
we may always estimate the extent of this 
latter lesion by the extent to which the upper 
fragment is drawn up. This was sufficiently 
illustrated in a dissection which my Senior 
Assistant House Surgeon, Dr. Grirdner, kindly 
prepared for me. Ho exposed the patella and the quadriceps with its 
broad lateral aponeurosis, which passes down, spreading out. to be in- 
serted finally into the sides of the tibia and fibula ;it their upper ex- 
tremities. He then divided the patella transversely with ;i chisel, 
leaving the aponeurosis untouched, and wo observed now that by no 
amount of pressure upwards short of that which would cause ;i laceration 
of the aponeurosis, could the upper fragment be made to ascend more 
than half or three-quarters of an inch. By cutting the aponeurosis on 




Transverse fracture of the patella. 



540 



J'KACTURES OF THE PATELLA. 



either Bide, the fragment could be pushed up further, but the cutting 
had to be very extensive before it could be pushed up three inches, as 
has happened in some of the recent cases which have come under my 
observation. Such extensive separation, therefore, implies necessarily 
extensive laceration of the aponeurosis. 

Fig. 210. 




Separation of the fragments in moderate 
flexion when the whole aponeurosis and 
tendon is torn. 






Fragments separated by forced flexion 
of the knee. 



There is another anatomical lesion, the existence of which it may be 
proper to assume in the majority of cases, although we have not the 
means of demonstrating its occurrence. The posterior wall of the bursa 
in front of the knee is probably lacerated, and the joint surfaces, or 
articular synovial capsule is made to communicate freely with the cavity 
of the bursa. 

This bursa is usually present in adult life, and is especially well de- 
veloped in males. Its posterior wall is composed of a thin synovial 
membrane, which is in direct contact with the front of the patella and its 
immediate investments ; so that a separation of the fragments to the ex- 
tent of half an inch could scarcely occur without laying open the bursa. 
The exception must be found in those cases in which the bursa is not at 
all, or is only imperfectly developed, or the fracture has taken place at 
a point which does not exactly correspond to the under surface of the 
bursa. 

I have' once or twice observed, a few days after the fracture, a fulness 
in front of the patella so defined as to seem to indicate that the bursa 
had not been torn, but that it had inflamed and become filled with serum; 
but I imagine that this appearance might be presented sometimes when 
a communication with the joint had been established, and the bursa had 
become filled, its anterior wall being simply pressed forwards by the fluids 
of the joint. 

There remains then, usually, in front of the joint nothing but the skin 
and a thin layer of areolar tissue, or probably the skin alone, which if 
it were not at this point very redundant and elastic would often be torn, 



FRACTURES OF THE PATELLA. 541 

rendering the fracture compound. In no case under my notice has the 
skin been torn as an original accident, however much the fragments 
may have separated : but in one case, not recorded in the preceding re- 
port, but which was at the time under the care of Dr. Erskine Mason, 
the skin was torn in a subsequent accident — a rupture of the new liga- 
ment — the fragments being separated very widely. Suppuration of the 
joint ensued, and it became necessary to amputate at the knee-joint by 
Cardan's method. After which he made a good recovery. 

It has been found possible sometimes for the patient, immediately after 
the accident, to continue standing, or even to walk by exercising great 
care, but in most cases the patients have at once fallen to the ground and 
been unable to rise. 

Very speedily, often within a few minutes after the injury is received, 
the joint appears swollen. This early swelling must be in part attributed 
to the effusion of blood into the joint from the broken patella and adja- 
cent tissue. The presence of blood in the joint was demonstrated in 
case 90. and there can be no reason to doubt that it is often, perhaps 
always, present in the joint in some amount, after the fracture, where it 
probably undergoes a pretty rapid disintegration and is mostly absorbed. 

There is quite often, also, at an early date, considerable discoloration 
of the skin on the sides and back of the knee, caused by the infiltration 
of the blood into the subcutaneous areolar tissues. 

A synovitis and bursitis (when the bursa is torn) are inevitable also ;, 
the amount of inflammation being more or less in different cases, but 
being, in most cases sufficient to fill the joint with serum and probably 
some lymph, within the space of a few hours, or days at most. This 
effusion, caused by the synovial inflammation, generally begins to disap- 
pear within a week or ten days, and cannot usually be detected after the 
second week ; but meanwhile, pretty often, a more or less extensive cel- 
lulitis ensues, involving the front and sides of the knee and extending 
some distance up and down the limb. Usually this is moderate, but it 
has occasionally, and especially when injudicious pressure has been em- 
ployed, resulted in suppuration of the areolar tissue. 

Mode of Union and Prognosis. — The frequency with which, accord- 
ing to my observations, the bond of union has given way at some subse- 
quent period, renders it necessary that I should speak of the character 
of the union and the prognosis relating to primary accidents, and the 
character of the union and the prognosis relating to secondary accidents, 
separately. 

Character of the Union and Prognosis in Primary Accidents. — In 
my published rases the bond of union is known to have been fibrous in 
84, and in no case is it known to have been bony; but quite often it has 
been thought, when the patient was first dismissed, that the union was 
bony, and in almost every case a much later examination has shown that 
it was fibrous. When the dressings are first removed there is often such 
a decree of hardness of the tissues between the fragments as to lend one 
to suppose that the fragments have united by bone, and they are so fixed 
that they cannol be made to move separately, but which deceptive ap- 
pearance is removed in the course of a few weeks or months. I do not 
know positively that in any case the union was by bone. If I were to 



542 FRACTURES OF THE PATELLA. 

state my convictions, I would say that probably none of the tabulated 
transverse fractures were united by bone; and that only a small propor- 
tion of the vertical and comminuted fractures were thus united. I do 
not deny the possibility of union by bone. A few cases, verified by the 
autopsy, have been reported from time to time, but I have never seen but 
one case verified by dissection, and to this I shall refer again hereafter. 

Bony union was for a long time considered impossible. Pibrac chal- 
lenged all surgeons of his time to show him a patella thus united. 
Dupuytren, who thought he had obtained a union of this kind, offered 
for the patella of his patient its weight in gold. According to Velpeau, 
however. Wilson and C. Bell had seen a case of bony union ; Lalleman 
had demonstrated its possibility, and there was a specimen of it in the 
Hunter museum. 1 

The length of the fibrous bond, in primary cases, is usually about half 
an inch, and ranges from one-quarter of an inch to five inches : but of 
the whole number recorded by me, there are only four in which the new 
ligament is more than one and a half inches in length. These latter are, 
therefore, exceptional cases : and were rendered so by the greater violence 
inflicted, and the more extensive rupture of the aponeurosis and muscle, 
or by injudicious treatment. 

I will relate the cases, in order that we may appreciate where the 
responsibility generally lies, when fragments unite with so much sepa- 
ration : 

I found Samuel Hanna, set. 38, in my ward at Bellevue, June 1, 1875, 
admitted on account of an abscess which had formed without any appre- 
ciable cause in the areolar tissue, just above the left knee. He had an 
old fracture of the patella in the same limb, the fragments being sepa- 
rated nearly four inches. He was unable to extend the limb by muscular 
action, there being apparently no bond of union between the fragments. 
He gave the following account of the injury : The accident occurred 
in December, 1871, about three years and five months before. He was 
immediately taken to Bellevue Hospital. On the fourth day the limb 
was laid upon an inclined plane. On about the seventh day a plaster-of- 
Paris splint was applied, from the foot to the hip. He was permitted to 
go about on crutches. When the splint was removed the fragments were 
separated two inches. He has had no treatment for the fracture since. 

John Sharkie, set. 24, a soldier in the British service, was struck in 
the right knee while he was sitting with his leg bent under him. He 
was immediately put under charge of the surgeon of the 89th regi- 
ment of infantry. Severe inflammation and swelling ensued, and no 
apparatus was employed until the twelfth day ; a compress was then laid 
over both fragments, and they were bound on with a roller, the limb being 
laid upon an inclined plane. The bandages were removed at the end of 
four months, when the upper fragment at once drew up toward the body. 
It was eighteen months before he could walk without a cane. This is 
the account given to me by himself. 

Twenty-nine years after the accident, March 27, 1855, I found, when 
the limb was straight, that the upper fragment lay two and a half inches 

1 Velpeau, Anat. Chir., vol. 2, p. 400. 



FRACTURES OF THE PATELLA. 543 

above the lower, and when the limb was flexed it separated five inches. 
No trace of a ligament or other bond of union could be felt. He walked 
well, without a cane, there being very little or no halt, but he could not 
walk fast. 

Jeremiah Murphy, of No. 3 Bridge Street. New York. ret. 06. broke 
his left patella transversely, below the middle, by a fall upon the knee. 
A surgeon was called, and applied bandages. He was four or five 
weeks in bed. and then went out. using a cane. The fragments were 
then found to be much separated. Aug. 30, 1879. seventeen years after 
the accident. I found the fragments separated 3J inches when the leg was 
straight, and -4J when it was flexed. Fragments of normal size. No 
ligament between the fragments : but along their outer and inner margins 
the tendinous fibres of the quadriceps are prominent, and especially on 
the outer side. He cannot extend the leg by muscular action when sit- 
ting, but he can flex it to an acute angle with the thigh. Standing, he 
can flex and extend it perfectly. In extending he turns the foot out. in 
order to bring into action the outer portion of the quadriceps. He has 
always, since this accident, been somewhat lame, but could walk several 
miles and carry loads without a cane. 

May 25, 1879, he slipped and fell, striking upon the right knee, and 
breaking the right patella transversely about its middle. June 1. a sur- 
geon applied adhesive strips over and above the patella, then a plaster- 
of-Paris bandage from the hollow of the foot to above the knee. Frag- 
ments were separated an inch or more. Began to walk. A few days 
later the leg suddenly gave way. and he fell back. The skin became 
discolored, and it swelled very much. 

When he consulted me the fragments of the right patella were sepa- 
rated If inches, when the limb was straight, and three inches when it 
was flexed. He walked slowly without a cane, but was in constant fear 
of falling. I advised him to submit to a second trial to obtain a more 
satisfactory result in the case of the right leg. but he declined to do so. 

Peter Waters, aet 23, mason. 1830 Third Ave., while running caught 
his heel, and in his effort to save himself fell back. At this moment he 
heard his patella crack, and found at once that he could not stand. 

On the following day. April 30, 1874, he was admitted to Bellevue. 
The fracture was found to be transverse below the middle, and the frag- 
ments separated three-quarters of an inch. Evaporating lotions were 
applied. 

May 5. A silicate-of-lime splint was applied, the fragments having 
been previously approximated by adhesive >trips locked over the front 
of the patella. 

loth. Splint removed, as it did not have sufficient firmness, and 
pla-ter-of-Paris splint substituted, which was Boon cut open. 

16th. Seventeenth day. Discharged at his own request, with in- 
structions to report from time to time. (No farther record.) 

1 saw and examined this man Oct. 22, 1879, more than five yean 
after the accident. The fragments were Beparated two inches, and united 
by a firm ligament. No hypertrophy of fragments. lie can use the leg 
almost as well as the other — can flex and extend fully, and run up and 
down stairs. 



544 FRACTURES OF THE PATELLA 

When he Left the hospital, with the plaster splint on, lie wore it about 
two weeks; the joint was then very stiff. On taking off the splint he 
moulded a piece of sole-leather and made for himself a knee-cap, which 
he wore a few weeks longer. Gradually the anchylosis disappeared, and 
in about one year he resumed work as a mason. 

I have found the fragments tilted, in consequence of a yielding of the 
new ligament, or because of a pressure of the bandages, in four cases. 
In three of these it was the inner portion of the ligament which had 
given way, and in one the outer. If from so few examples it is proper 
to infer the existence of a rule, and to declare that the inner portion 
gives way most often, we may perhaps find a reason for the rule in the 
fact that the inner portion of the quadriceps is more powerful than the 
outer portion, and might therefore act more energetically upon the inner 
margin of the upper fragment, and cause it to separate more widely from 
the lower. 

Malgaigne made the same observation which I have made, and does 
not hesitate to speak of it as a rule, or absolute law; declaring that it 
is always the inner portion which is found elongated ; but I have men- 
tioned one example in which the fact was otherwise. Boyer also alludes 
to the tendency in the upper fragment to tilt outwards ; and both of 
these writers think that the phenomenon is due to the manner in which 
the pressure of the apparel was made to bear upon the upper end of the 
upper fragment. The upper margin of this fragment is not horizontal, 
but oblique, its outer portion being considerably above the plane of its 
inner portion; so that any form of adjustment in which the plane of 
pressure from above is horizontal, will press more effectively upon the 
outer than upon the inner portion, and cause the upper fragment to tilt, 
or incline outwards. It seems to me that both unequal muscular action 
and the direct but unequal, or maladjusted mechanical pressure of nearly 
all forms of apparel employed to bring down the upper fragment, may 
be considered as alike responsible for this result. This, as will hereafter 
be seen, I have sought to avoid by employing a somewhat elastic cotton 
roller for the purpose of making the downward pressure. 

Occasionally it is found, when the fragments have united, that one or 
both of the fragments are inclined a little forwards at the point of frac- 
ture, forming an angle salient in front. Usually it is but one of the 
fragments that is thus inclined ; and in most cases, if not in all, that 
fragment which is the longest is the one which projects. Thus, of my 
published cases, 9 and 31 were transverse and in the upper third, and 
when union was completed the upper margins of the lower fragments 
overhung the lower margins of the upper. 

The longest fragment resting upon a convex surface, and being no 
longer held in position by a counter-force, the ligamentum patellae or the 
quadriceps must inevitably incline forwards. Indeed, I have seen this 
condition present in a recent fracture before any apparatus had been 
applied ; but in such cases very slight pressure, applied from before 
backwards, was sufficient to restore it to place ; and it is quite certain 
that for this result after union is consummated, the apparatus employed 
to bring the fragments together is mainly responsible. Both the quad- 
riceps and the ligamentum patellae have their insertions nearer the ante- 



FRACTURES OF THE PATELLA. 545 

rior than the posterior margins of the patella, a thin layer of tendinous 
fasciculi actually traversing its anterior face. The upper and lower 
margins of the patella, therefore, present no elevations for the applica- 
tion of concentric pressure : and if by any form of apparatus, except 
Malgaigne's hooks, concentric pressure is made, it must be accomplished 
by causing a depression in these firm ligamentous bands, or a recession 
from the tegumentary surface, in order that the concentric forces may 
have a point d'appui. This pressure must depress the corresponding 
margins of the two patellar fragments, and elevate their broken margins ; 
and in this case the longest fragment will suffer the greatest displace- 
ment. To a certain degree this must occur even with Malgaigne's hooks, 
as we shall easily see when we consider their mode of application as 
recommended by himself; but in a much less degree than by any of the 
usual modes of treatment : such, for example, as those in which two hard 
crescents or a padded ring are employed to bring the fragments together. 
No doubt it is occasioned also sometimes by the pads which some sur- 
geons place in front of the patella, and which get displaced and press 
unequally. 

Both these displacements, namely, the tilting and the forward pro- 
jection, are imperfections which contribute their proportion to the subse- 
quent maiming : causing in the one case a relative loss of strength in the 
ligament, and in both cases causing some irregularity in the movements 
of the patella over the surface of the femur. 

There is another form of displacement to which I have not yet re- 
ferred, but which seems in most cases to be temporary, although it is 
probable that it is not in all cases, namely, a simple lateral displacement. 
Tli is existed in case 9, before the treatment was fully terminated. The 
upper fragment was found displaced inwards one-quarter of an inch, and 
it could not be moved from this position — at least not without greater 
force than it seemed proper to apply. In this case, however, the frag- 
ment subsequently, Avhen he had used the limb some time, gradually 
loosened and resumed its natural position. I think the same happened 
in one or two other cases, and that they subsequently came into line. 
Probably in each case it was caused by the lateral pressure of the 
bandage or of other parts of the dressing, and might, therefore, have 
been avoided. It is easy to imagine that if the fragments are thus dis- 
placed the bond of union may be imperfect or unequal on the two sides, 
or that it might diminish the chances of union, and in either case the 
evil results might be permanent and serious. 

Hypertrophy of the fragments. This must be distinguished from an 
-'if] i ;i- is frequently observed along the margins of the frac- 
ture, and which is never considerable, only can-in L r ;> slight irregularity 
in the surface of the bone, but which may be present without any peri- 
pheral enlargement or expansion of the fragments. 

This actual hypertrophy has been observed by me in nine cases, 
namely, twice in the upper fragment alone, once in the lower fragment 
alone: and six times in both. The occasional hypertrophy of the frag- 
ments has been noticed by other writers, and Malgaigne has furnished 
two illustrations. Tic- same thing is known to happen pretty often in 
some of the long bom-- when broken near theii extremities, where the 

35 



54(3 FRACTURES OF THE PATELLA. 

structure is cancellated. I have noticed it often in the fracture of the 
humerus near its lower end, the lower fragments being in all such cases 
the ones which become hypertrophied. In the case of the humerus the 
hypertrophied fragment, sometimes after many months or years, is found 
to diminish ; but whether such a gradual diminution in size takes place in 
examples of hypertrophied patellae I am not certain. It has not seemed 
to me that it does occur. 

Period required for Recovery of the Perfect Use of the Limb. — I will 
quote what Malgaigne says upon this subject : " Camper has stated that 
in one or two years the power is recovered, whatever may have been the 
interval between the fragments. An evident exaggeration, since he him- 
self speaks of a lady with a separation amounting to three fingers' breadth, 
who still limped four years after the receipt of the injury. Mr. Benja- 
min Bell makes one inch the limit of separation, allowing for the resto- 
ration of the firmness of the knee ; Boyer follows him ; M. Velpeau, on 
the contrary, affirms that he has seen the functions of that joint com- 
pletely reestablished, with an interval of two or three inches between 
the fragments. Such assertions are, in my opinion, only accounted for 
by some inaccuracy of examination, and for my own part I have never 
seen the functions of the limb completely restored, even when the sepa- 
ration was limited to one-third of an inch." 1 For myself, I have seen 
three or four perfect results, so far as the use of the limb is concerned. 
For example, in case 31, after nineteen years, when I examined the patient 
carefully, there was not the slightest difference in the freedom of use of 
the two limbs ; yet the union is by a ligament of three-quarters of an 
inch in length. 

The fact seems to be, that more or less loss of freedom in the motions 
of the joint, and of strength and stability in the limb, remains in the 
majority of cases for a long period of time, and often during life ; but 
that in a few exceptional cases, where the separation does not exceed 
one inch, the functions of the limb are completely restored within one or 
two years. It is remarkable, also, how well the functions are restored, 
after a long time, in some cases where the separation is very great, as, 
for example, in case 23, in which the separation was five inches when 
the knee was flexed, without bond of union of any kind; yet when I 
examined him at the end of twenty-nine years he walked well without a 
cane, and with very little or no halt, but he could not walk fast. 

The first and main impediment in the restoration of the functions of 
the joint is the anchylosis, which is in many cases at first nearly com- 
plete. This anchylosis being due to the passive contraction of the 
articular ligaments, as a consequence of long disuse; to adhesions and 
inflammatory infiltrations among the torn muscular and tendinous fibres, 
and between these latter and the upper fragment of the patella as it lies 
more or less buried in the torn tendinous tissues. It is never safe to 
attempt to overcome this anchylosis by force, consequently the process of 
restoration must be slow and uncertain, and it will generally be found to 
be many years before the leg can be flexed upon the thigh to the same 
angle as in the case of the opposite limb. 

1 MalLcai^ne, op. cit., p. 606. 



FRACTURES OF THE PATELLA. 547 

In a certain degree, also, the changed relations of the fragments to 
the articular surface of the femur may be responsible for the lameness. 

As to what influence the nature and length of the new bond of union 
have upon the usefulness of the limb, lam prepared to say, first, that the 
fact that it is generally fibrous and not bony is probably of no conse- 
quence, provided the bond of union does not exceed one inch in length. 
It certainly is in no way responsible for the anchylosis ; and, as to its 
effect upon the stability or strength of the limb, there is no reason to 
suppose that this slight diminution in the range of the contraction and 
elongation of the quadriceps will have, after one or two years of use, 
any appreciable effect upon the stability of the limb. Indeed, so far as 
I have been able to ascertain, in most of these cases the patients have 
been able, after a time, to extend the limbs as completely if not as 
forcibly as before. 

If. however, the length of the fibrous bond is much more than one 
inch, there is generally an appreciable loss of the power of complete and 
fixed extension. 

We have had recorded too few well-attested examples of bony union 
to enable us to declare whether the fibrous union or the bony union is 
most liable to a secondary accident — a refracture. It would seem rea- 
sonable to suppose that the newly formed bone would be thinner than 
the original bone and less spongy, and that in consequence of its com- 
pactness and thinness it would break more easily under a cross-strain 
than would an equally thick, but flexible, ligament. It is well known 
that a rupture of the ligamentum patellie, or of the united tendon of the 
quadriceps, occurs much less often than a fracture of the patella. 1 

March 11, 1871. Miss E. B., of Hayesville, Ohio, a?t. 51, fell a dis- 
tance of several feet, striking upon frozen ground, breaking the left 
patella transversely below its middle. Dr. E. V. Kendig being called, 
sed the limb with a straight splint and adhesive plasters, which were 
removed in seven weeks. Inflammatory reaction was moderate. In ten 
weeks she began to use crutches. About this time I was consulted by 
letter, and was informed that the motions of the joint were quite limited. 
I advised continuance of passive motion, and use of the crutches. This 
practice was adopted, but gradually the motions of the joint ceased, until 
there was complete anchylosis. Subsequently she began to have pains 
in her left hip, then in the right, and in other parts of her body, espe- 
cially in the sternum, where a tumor formed of considerable size, which 
felt like bono, but which disappeared under the use of iodine. Her 
health Bteadily declined, and in the spring of 1S74 she began to take 
opium to relieve her pains. Her left femur was broken from some slight 
cause a short time before her death, which took place two years and six 
months after the fracture of the patella. 

Dr. Kendig, having made an autopsy, has kindly sent the specimen 
to me. Union of the two fragments of the patella has taken place by 
means of two thin plates of* bene, corresponding to the inner and outei 

1 " Relative Value of Bony and I - Union in Transverse Fracture of the 

Patella."' a lecture delivered at Bellevue Hospital, Dec. 1880, by the author, lied. 
- and Abstract, April, 1881, p. 195. 



548 



FRACTURES OF THE PATELLA. 



margins of the patella, leaving between them an open space, which in the 
recent state was probably, occupied by fibrous tissue. Of the two plates 
which compose the bond of union, the inner is much the largest. 

It is evident, upon the most superficial examination, that the least 
flexion of the limb would have been sufficient to have caused a rupture of 
the bony callus ; indeed, the outer plate was broken and partly destroyed 
in cleaning it. It will be inferred, also, from the description given, 
that the bony union did not take place at first, and that the treatment, 



Fig. 211. 



Fig. 212. 





Dr. Kendig's case of bony union after a fracture of the patella. (From author's collection.) 
Front view. Side view. 



which seems to have been judicious throughout, was in no way responsi- 
ble for the result. The bony union seems to have been the result of 
trophic disturbances in the osseous and articular structures, which 
brought about the anchylosis in spite of passive motion ; and which, by 
placing the new fibrous bond of union completely at rest, encouraged 
the formation of bone as a secondary event. 

My conviction is that a fibrous union of less than one inch in length 
is quite as advantageous as a bony union, and probably much stronger — 
a conviction which is enforced, also, by a case which Dr. James L. Little, 
of this city, has brought to my notice. John Mullen, set. 22, broke 
his left patella transversely below its middle in March, 1879. It united 
by fibrous tissue with a separation of half an inch. About five and a 
half months later he slipped in walking, and the same patella was found 
to be fractured at a point about half an inch above the first fracture and 
transversely. This had united also by fibrous tissue of the same length 
as the first. I saw him soon after he left St. Luke's Hospital, where he 
had been treated by Dr. Little. The three fragments were movable upon 
each other, and no doubt can exist as to the character of the accident. 
In this case at least, then, after the lapse of a little more than five 



FRACTURES OF THE PATELLA. 



549 



months, the new ligament has proven itself to be stronger than the 
original hone. The same is true also of the case illustrated in Fig. 213. 
Rupture of the newly formed Ligament. — In the prognosis of original 
fractures we have to include the danger of a rupture of the newly formed 
bond of union. Indeed, my statistics, already referred to. show a startling 
frequency of this accident. It is known to have occurred in twenty-five 
cases, and in two additional cases the ligament has given way partially. 

Fig. 213. 




Fracture of Ja>\ 1879. 




Fig. 213 represents the position of the fragments after two successive fractures, in the 
person of Dr. E. Cutter, of New York, examined by the author in 18S4. Actual size. 
Fragments united by ligament. The shaded lines represent new bone. 



Some of these cases were persons who sought my advice only after the 
treatment had terminated, and they might not therefore correctly repre- 
sent the true proportion in a given number of consecutive cases. On 
the other hand, it will be remembered that a considerable number of the 
one hundred and twenty— even tabulated cases were not seen or heard 
from by me. after the treatment was terminated; so that, on the whole, 
I think that twenty-seven out of every one hundred and twenty-seven 
represents fairly the average ratio of these accidents. 

A knowledge of tin- feet, which now for the first time has been re- 
vealed to me. is of the greatest importance, as indicating the necessity 
for gi in the use of the limb alter the surgeon lias practically 

dismissed the patient; bur it is reassuring to know that two-thirds of the 
whole number were ruptured yery soon after Leaving "IV the apparatus; 
that is, within ten week- after the original fracture had taken place; and 



550 FRACTURES OF THE PATELLA. 

that five of these took place gradually, commencing when the patient 
began to walk. Only two occurred later than five months after the 
injury, or about three months after the apparatus was removed. It would 
seem, therefore, that it is only necessary to provide against the accident 
during the first three months after removal of the splint, and that after 
tli is a rupture is no more likely to take place than if it had not been 
broken. 

Fracture of the Opposite Patella. — This has happened five times in 
the one hundred and twenty-seven cases, and was no doubt due in each 
case to the greater effort made by the quadriceps of the sound limb to 
sustain the body, when the equilibrium of the body had been disturbed. 

Character of the Union, and Prognosis after the Secondary Accident. — 
A majority of these cases refuse to unite again, even by fibrous tissue, 
whatever means may be employed ; and the few cases of union after 
rupture of the fibrous bond which have come to my knowledge, are con- 
fined almost entirely to those examples in which the rupture took place 
very soon after the apparatus was removed, and in which the limb was 
immediately subjected to treatment. 

"When the fragments do not unite the patients are for a long time 
seriously maimed, the limb lacking stability, and often giving way sud- 
denly under the weight of the body. In most of these cases, however, 
a judicious treatment, such as I shall hereafter indicate, will eventually 
give considerable stability to the limb, and enable the patient to walk 
with much safety and ease. 

Treatment, in Primary Accidents. — Our investigations have brought 
us to conclude that in a large majority of cases, under any plan of treat- 
ment, a fibrous union of the fragments is all that can be expected ; and 
that probably a fibrous union, with only a separation of a half or three- 
quarters of an inch, is as useful as a bony union. Probably more useful. 

The only methods which could encourage a reasonable hope of pro- 
curing a bony union, are Malgaigne's hooks, and wiring the fragments 
together. 

Malgaigne's hooks have hitherto not been proven to have accomplished 
this result, not even in the hands of the distinguished inventor. In fact, 

Fig. 214. 




Malgaigne's hooks. 



contrary to what I would have expected, there has been among the cases 
reported as many examples of fully recognized fibrous union, as have 
occurred where some other plans of treatment have been followed; the 
fibrous band has been no shorter ; and the number of cases in which a 
bony union has been said, but not proven to exist soon after the removal 



FRACTURES OF THE PATELLA. 551 

of the apparatus, is no greater than almost every other method has 
supplied. 

On the other hand, several cases have been reported of dangerous or 
disastrous inflammation induced by the hooks, and to this objection many 
other methods are never liable. There seems no possible reason, there- 
fore, why in any ordinary, simple transverse fracture, in which the original 
separation does not exceed one inch or even one and a half inches, the 
hooks should be employed : but in cases in which the original separa- 
tion exceeds this, and especially in cases of a refracture or rupture of the 
fibrous bond, accompanied with great separation, it is my opinion that 
Malgaigne's hooks are entitled to a farther trial. 

" That Malgaigne's hooks," says Yolkmann, ''have caused ulceration 
of the joints and death of the patient in a number of cases, is only too 
true : I myself know of two which occurred in the practice of friends, 
and which were never published ; and another sad experience was met 
with in my own clinic a number of years since." 1 A death occurred in a 
London Hospital from the use of these hooks. 2 

The modification of Malgaigne's method suggested by Yalette, of 
Lyons. 3 in the substitution of adjustable forks for the hooks, does not 
render the apparatus less liable to do harm. 

Farther modifications of the apparatus have been made by Levis, of 
Philadelphia, Yerneuil. Le Fort, and Trelat, but without materially 
diminishing the possible or probable danger. 

Severin was the first to suggest exposing the bone "by an incision, so 
as to refresh the surfaces directly;" ••which happily," says Malgaigne, 
•• was not done.'* 4 

Norris 5 declares that he knew of one case in which the fragments were 

sed and approximated by wire (Dec. 1842), and the patient died on 

the fourth day. Dr. J. Rhea Barton, of Philadelphia, operated in the 

same manner and his patient died. 6 Dr. Moses Gunn, of Chicago, lost 

hi- patient from suppuration. 7 Dr. Cabot, 8 of Boston, had the same 

result. Cooper 9 and Logan, 10 of San Francisco, made a similar opera- 

. and Dr. Byrd 11 says it was made " many years ago" by Dr. George 

M CI ell and, of Philadelphia. The precise dates and results of the three 

operations are not published. 

We are thus supplied with four cases in relation to which we have 
se information, namely, the cases reported by Norris, Barton, Gunn, 
and Cabot, in which the operation was made without Lister's antiseptic 
precautions, and all of the patients died in consequence. 

8 the introduction of Mr. Lister- antiseptic treatment it has been 

thought, by some, that the operation of exposing and wiring the fragments 

• uld be made with more safety. The operation, under anti- 

Volkmann, Cent. f. Chir., 18*0 ; 24. ' 2 London Lancet. Nov. 22, 1879. 

h ed. "1" t:. . 'ill. 

■• -. chap*. 7. Malgaigne, op. ''it., torn. i. p. 775. 
N rris, Am. Journ. Med. 8ci., Jan. 1842, p. 51. 
* B Grrosa's Surj . vol. i. p. lo<»4 

' i. Rec., July 3, 1882 8 Cabot, Ibid. 

'" -. l s »;l . 

►urn.. Dec. r 
11 McLelland, N. Y. M 



552 FRACTURES OF THE PATELLA. 

septic precautions, has therefore been lately practised by a considerable 
number of surgeons; notably by Van der Meulin, of Utrecht, in July, 
1879, by Cameron, 1 of Glasgow, Rose, 2 of London, Mr. Lister, 3 Metzler, 
Socin, Langenbeck, Trendelenberg, R. Bell, Henry Smith, 4 and Wyeth. 5 

I shall not think it necessary to examine all of the cases reported as 
having been wired under antiseptic precautions. I will however take 
the liberty of presenting a summary of the discussion upon this subject 
in the Societe de Chirurgie of Paris, Oct. 7 and Nov. 4, 1883, as I find 
it in the Virginia Medical Monthly for Jan. 1884, p. 649 : 

ww M. Chauvel had collected the records of 43 cases, in 38 of which 
the bone had been broken without solution of continuity of the overlying 
structures. In one set of cases, the sutures were employed after all other 
methods had failed ; in the other class, they were employed as soon as 
the injury was received. In 18 cases, two sutures were employed and 
the substance generally used was silver wire, though occasionally catgut 
and silk were employed. All the details of the antiseptic method were 
rigorously carried out. 

" The results of the operation were very various ; in twelve cases the 
reaction was violent, while in eight it was moderate. The results were 
said to have been favorable in seventeen cases ; in twelve cases bony 
union occurred ! while in seven it was fibrous ; three cases terminated 
fatally, and in one the thigh was amputated ; the result in the other cases 
is not stated. 

" M. Chauvel, comparing these results with those obtained by other 
methods, concludes that the suture may be useful when all other methods 
of treatment have failed, but it should not be practised as a general thing 
on account of the dangers incident to it. 

" M. Pozzi had performed the operation once on a lunatic with suc- 
cess, so far as the bony union was concerned, but the joint was very stiff 
when motion was first tried and in attempting to move the joint the frac- 
ture was reproduced. 

" M. Le Fort said he believed in bold surgery when the end to be at- 
tained justified the risk ; but in the present case there was nothing what- 
ever to justify such temerity. MM. Despres and Labbe entertained 
similar opinions, and M. Trelat thought the operation proper only after 
all other modes of treatment had failed. 

" M. Richelot thought the dangers incident to the operation of open- 
ing the joint were far too serious to make the operation justifiable except 
in very exceptional cases, and he called attention to the fact that with 
fibrous union, a very excellent limb often results. 

" M. Gillette strongly opposed immediate arthrotomy unless there was 
an external wound. 

■ ; M. Verneuil protested against the procedure. The results of the 
' ordinary treatment were far from being bad — the immense majority of 
patients treated in a hospital being cured and able to walk well — while 

1 Cameron, Glasgow Med. Journ., Julv, 1878, vol. x. 

2 Rose, Lancet, Nov. 22, 1879. 

3 Lister, British Med. Journ., 1877, vol. 2, p. 850. 
i See Poinsot, Rev. de Chir., t. 2, 1882, p. 60. 

5 "Wyeth, Med. Record, July 3, 1882. 



FBACTUKES OF THE PATELLA. 553 

in the forty-three cases of suture, there were three deaths, one amputa- 
tion, and ten absolute failures." " 

Among all those present, only M. Lucas-Championniere took a different 
view of the subject. 

It will be proper for me to add that in the ease operated upon by 
Wyeth, and already referred to, it became necessary to amputate the 
thigh, ami Dr. Wyeth also informs me that Dr. Bull, of this city, has 
lost a patient in the same way. 

Says Volkmann. " I concede with Kocher, that laying open the articu- 
lation for the purpose of making a bone suture is not justifiable, at least 
it should not be recognized as a method for general adoption." 1 

To the testimony thus accumulated against this operation. I wish to 
add my own. that it is offering a very grave and dangerous substitute for 
others perfectly safe, and, so far as is yet proven, equally efficient methods; 
it is hazarding the life of the patient without offering any equivalent. 
Indeed I do not see why anything less could be reasonably expected from 
this kind of surgery than tedious recovery, anchylosis, amputation, or 
death : at least in a considerable proportion of cases, and this is precisely 
what has happened. 

Kocher, recognizing the dangers attending the use of bony sutures, 
substituted a metallic suture which, by means of a curved needle, was 
passed under the upper and lower margins of the fragments and secured 
in front of the patella by twisting the extremities. It is difficult to see 
how this method should materially diminish the dangers, as the suture, 
or ligature more properly, "is drawn through the joint."' (Volkmann.) 

Volkmann 2 says : * ; Long before the introduction of antisepsis I at- 
tempted suture of the tendons in fracture of the patella, and though the 
ligature was left in place only a very short time, until the plaster-of- 
Paris bandage which was at once applied had hardened, I twice met with 
very satisfactory success. The two cases were described in Virchow's 
and Hirsch's Jahresberiekt, f. 1868, Bd. II., p. 364. ' In two cases I 
drew through the tendon of the quadriceps and the ligamentum patella, 
while the integument was strongly retracted, at first in an upward, then 
in a downward direction, a simple loop of thread, and knotted the same 
over the patella : by this means the fragments were brought into contact, 
and ;it the same time the prominent edges were depressed. Then a very 
tightly fitting plaster-of-Paris bandage was applied, and directly after it 
had hardened, a fenestra a- lame as a two-cent piece was cut into it, cor- 
ading to the spot where the Ligatures had been tied, and the latter 
were cut and withdrawn. In one case, firm osseous union resulted; in 
the other, a very narrow, fibrous, intermediate substance was formed; in 
a third case, one of my clinical assistants applied the bandage in the 
same manner, and though the ligature was removed after remaining in 
place hardly a quarter of an hour, ulceration of the articulation and death 
from pyaemia ensued.' Tie- autopsy showed that in this unfortunate 
•he ligature had been introduced too deeply, ami transfixed the 
joint, and that the plaster dressing bad not been padded, but applied 
directly to the limb after enveloping the latter in moist blotting paper. 

1 Volkmann, Central, f. Chir.. 1880, 24. - lh\d. 



554 FRACTURES OF THE PATELLA. 

More recently I repeated the above operation with some slight variations, 
and the result was all that could be desired." 

One would suppose that a single experience such as that related above 
by Volkmann would have been sufficient. 

Volkmann 1 advises opening the joint for the purpose of evacuating 
the extravasated blood; but Kocher calls attention to the fact that the 
blood has been found coagulated as early as the third day, and he thinks 
therefore that the opening ought to be made as soon as possible. Schede 2 
proposes to wash out the joint with carbolized water; but Kocher says 
he has seen this produce carbolic acid poisoning. In regard to sug- 
gestions of this character, as applied to simple fractures of the patella, I 
do not think it necessary to say more than to call the attention of sur- 
geons to them. 

Lastly, it is proposed to aspirate the joint for the purpose of evacuating 
the synovial fluids, and thus relieve the distention which tends to separate 
the fragments. 

The objections to this procedure are that it is not unaccompanied with 
danger ; that the joint will, in most cases, become speedily refilled; that 
usually the effusion begins to be absorbed as early as the seventh clay 
and soon disappears entirely, so that practically it does not seriously 
interfere with the process of union. 

In a case aspirated by Dubrueil 3 purulent arthritis ensued, but the 
final result is not given. In a case reported by Dr. Robert McDonald, 4 
aspiration of the knee-joint having been made for chronic effusion, in- 
flammation ensued ending in death on the seventh day. 

And in the same manner Dr. George H. Hammond, one of the house 
staff at Bellevue Hospital, lost his life in 1881. 5 

Cutting the quadriceps, a method said to have been adopted by Mr. 
Gould, 6 demands a very extensive subcutaneous incision, as any one will 
easily convince himself by looking at this muscle, with its broad and 
strong tendinous insertion into the top and sides of the patella-; and I 
venture to say that no surgeon has divided all of its fibres, or even the 
fibres of the rectus, in his subcutaneous incision, and certainly not with- 
out carrying his incision freely into the upper part of the joint. 

The method employed by Oilier, Groujon, and Wyeth (example 47 of 
my published cases), of injecting between the fragments fresh marrow 
cells, has as yet yielded no results. Nor do I think it is likely to suc- 
ceed for many reasons, and especially because the "germs" cannot be 
placed actually between the fragments without being in the cavity of the 
joint, where of course they could serve no purpose. To place them in 
the thin tegumentary covering, which alone remains, when the separation 
exceeds half an inch, would be, I think, equally useless. 

Finally, in order to accomplish the best results, w r ith the least possible 

1 Volkmann. Kocher, loc. cit. 

z Schede, Central, fur Chir . 1877, p. 657. 

3 Dubrueil, Bull. de Soc. Chir., Oct. 1872, p. 488. 

4 McDonald, Am. Journ. Med. Sci., April, 1873, p. 548; from Irish Med. Gaz. 
■'■ Med. Record, June 11, 1881. 

6 Gould, debate on Mr. Rose's Case, Am. Journ. Med. Sci., Jan. 1880, p. 278 ; 
from Lancet, Nov. 22, 1879. 



FRACTURES OF THE PATELLA. 555 

danger to the life or limb, that is, to produce the shortest ligament, while 
the complete integrity of the joint is preserved, there are presented four 
simple indications of treatment, namely : 

First. Approximation of the lower fragment to the upper by straight- 
ening — extending — the leg upon the thigh. 

Second. Securing immobility of the knee-joint by a splint. 

Third. Relaxation of the quadriceps muscle. This indication is ac- 
complished in a small degree by flexing the thigh upon the body; but 
the effect of this posture is not so great as some writers have supposed. 
The quadriceps has but one origin from the pelvic bones, and conse- 
quently flexion of the thigh does not very greatly relax its muscular 
fibres. Yet that it possesses some value in this direction is easily demon- 
strated by experiment. The quadriceps is chiefly relaxed by extending 
the leg upon the thigh, that is, by placing the limb in a straight position 
and maintaining it in this position. 

The fourth indication is to approximate the fragments by direct 
pressure ; so far as this can be done, without inflicting serious injury 
upon the integument, or other structures. Without this pressure the 
relaxation of the muscle will not bring the fragments into actual juxta- 
position, or even make them approximate this condition. 

In order to make direct pressure, surgeons have devised a great variety 
of methods ; most of which are liable to the serious objection that they 
press too tightly upon the entire circumference of the limb to render 
them perfectly safe under all circumstances ; and especially when the 
opposing forces, which are intended to approximate the fragments, are 
applied with the view of securing absolute coaptation, as many of the 
inventors declare to be their intention. That danger exists from this 
source, the following case will illustrate: "A vine-dresser, set. 40, of a 
I constitution, fell, and received a simple transverse fracture of the 
patella, on the loth of January. The medical officer called upon to 
attend him applied first a bandage, for the purpose of drawing together 
the fragments, and afterwards a starched bandage, extending from the toes 
to the upper part of the thigh. The limb was placed upon an inclined 
plane. The patient was visited a few times, but, as he scarcely suffered, 
the apparatus was in no way disturbed. On the first of March (sixteenth 
-he attendant returned to remove the bandage, when the odor arising 
from the limb led him to believe that gangrene had taken place." Dr. 
Defer, who was called, found the toes, which were not covered by the 
band a pletely insensible and mummified." The bandage being 

removed, the gangrene was found to extend to within seven inches of the 
knee. The ankle-joint was opened and the ligaments destroyed. The 
bones of the leg were also exposed in their lower third, and the tendons 
were in a sloughy state. Amputation was performed, and the patient 
recovered. 1 

In case 28 of my published cases, plaster of Paris had been upon the 
limb one week when gangrene was threatened, and the plaster had to be 
removed. Cases 87 and LOO illustrate the danger also of tighl bandages 
in causing gangrene after a fracture of the patella. 

1 Amer. Journ. Med. Sci., vo\. xxiv. \>. \<','2.. from Gaz. M «'< 1 . No. 28. 



or>6 



FRACTURES OF THE PATELLA. 



Dr. Dorsey, of Philadelphia, employed an apparatus which will serve 
to illustrate in its most simple form the principle of approximating the 
fragments by the use of a splint and bandage. His apparatus consisted 
of a piece of wood half an inch thick and two or three inches wide, and 
long enough to extend from the buttock to the heel ; near the middle of 
this splint, and six inches apart, two bands of strong doubled muslin, a 
yard long, are nailed. The splint is then cushioned, and the limb laid 

Fig. 215. 




John Syng Dorsey's patella splint. 

upon it, a roller being first applied from the ankle to the groin, encom- 
passing the knee in the form of the figure of 8 ; after which the two 
muslin bands are secured across the knee in such a manner as that the 
lower one shall draw down the upper fragment, and the upper one elevate 
the lower fragment. 

Sir Astley Cooper employed two methods of approximating the frag- 
ments, which will be sufficiently illustrated by the following woodcuts : 



Fig. 216. 




Sir Astley Cooper's method by circular tapes. 
Fig. 217. 




Sir Astley Cooper's method by a leather counter-strap. 



FRACTURES OF THE PATELLA. 
Mr. Lonsdale devised a very complicated apparatus. 
Fig. 218. 



557 




Lonsdale's apparatus for fractured patella. — A B. Two vertical iron bars, each supporting 
a horizontal one: these horizontal arms slide upon the vertical bars, but can be secured at 
any point by the screws C D. To the horizontal beams are attached other vertical rods, 
which are movable, and yet fixable by screws, as at E. Finally, to each of these last upright 
pieces is fixed an iron plate, F F, by means of a hinge-joint, which keeps the patella in place. 
The foot-piece is movable up and down upon the main body of the apparatus, and can be 
made fast at any point, so as to adapt the splint to limbs of different lengths. 

The apparatus devised by Lausdale, U. S. N., is more simple than 
Lonsdale's, but both of them can only approximate the fragments when 




Lausdale's apparatus 



they press very firmly, and then they will necessarily tilt the fragments 
and expose the patient to the risk of ulceration at the points of pressure. 



Wires in semicircular form (A), the posterior part 
of each segment ( Ii) being curved upwards and the 
sides a little depressed. A shoulder is formed (C) on 
each side of the segments for the reception of the 
two straps (D), which connect them, and projects far 
enough on each side to permit the wires to be bent 
downwards at right angles with the shoulder, and 
descend perpendicularly to the slot or mortise (E) 
which is placed near each end of the block ( F). 




't apparatus. 



This happened in the only case which I have seen which had been treated 
by Lausdale's apparatus on the fifth day after it was applied. This is 



558 



FRACTURES OF THE PATELLA. 



the case of Assist. Surg. Meyers, reported near the close of this chapter. 
In neither of these forms of apparatus can bandages be properly applied 
to restrain the tilting of the fragments, and to give the knee-joint a 
smooth and equal pressure when it is swollen, as it usually is. 

The apparatus of R. E. Beach, of Illinois, is liable to the same ob- 
jection. 1 

Fig. 221. 




Beach's apparatus applied. 

The device of J. H. Hobert Burge, of Brooklyn, in which the frag- 
ments are approximated by carefully adjusted leather pads, operated 
upon by weights, cords, and pulleys, is too complicated, and possesses 

Fig. 222. 




Turner's apparatus. 

no marked advantages over the simple roller employed in my own dress- 
ing. 2 

The apparatus of Dr. Turner, 3 of Brooklyn, and of Dr. John A. 

1 Beach, St. Louis Med. and Surg. Journ., Jan. 1875. 

2 Bur^e, Med. Record, April 15, 1868. For illustrations see 5th ed. p. 471. 

3 Turner, Med. Rec., July, 1867. 



FRACTURES OF THE PATELLA. 559 

Wyeth, of this city, involve the same principles, and are equally liable 
to objections, on account of the limited surface against which the pres- 
sure is made. 

In Dr. WyethV apparatus the phalanges of the pad furnish a protec- 
tion to the vessels which course along the sides of the knee, and upon 
which the vitality of the integuments of the front of the knee mainly 
depends. 

Gibson, of St. Louis, has revived, in a modified form, the circular ring 
of Albucasis." Drs. Eve. of Xashville. and Blackman, of Cincinnati. 
have spoken favorably of this method. 3 Its application must, however. 
be limited to such cases as are unattended by inflammation, and can 
tolerate the pressure applied only to a small point of the surface. It is 
essentially the same as Beach's apparatus, but has the advantage of being 
more simple. Its efficiency depends upon its holding firmly upon the 
fragments, and not permitting them to slide from its grasp. All the 
tendinous insertions into the patella are continuous with the anterior mar- 
gins and surface of the bone : so that there is no natural sulcus to receive 
the ring, or uplift against which the ring or any similar form of dressing- 
can obtain a bearing, unless it is very firmly pressed into the tissues 
above and below, as I have before explained. Such pressure as is re- 
quired in the case of a ring, or any similar hard and unyielding mode of 
pressure, will not often be borne by an inflamed and swollen structure. 

Plaster-of-Paris and all other forms of immovable dressing do not pos- 
sess "aie single point of excellence or advantage. "When first applied 
they are liable to constrict the limb dangerously; and how insidiously 
a fatal gangrene may progress, giving no sign either by pain or general 
disturbance until the destruction is nearly complete, the case seen by 
Defer, and referred to in the preceding pages, will show. The cases 
which I have reported also in the preceding pages demonstrate how 
inefficient these dressings are as means of approximating the fragment- : 
the examples of the widest separation being drawn almost exclusively 
from cases treated by the plaster of Paris or the silicates. The dress- 
which within a few days or hours are apt to become very tight in 
quence of the increased swelling, soon begin to loosen, from the 
fence of the swelling at first, and finally from atrophy of the 
muscles and other soft tissues, and the limb lies loose in its case, which 
may not even touch the patella, much less make any effective pressure 
upon it. Whatever the result may be under such circumstances, ><» far 
as the separation of the fragments is concerned, the dressing has nothing 
with it. It may be that the final separation will be found to be 
very little, but. if it is. it would have been the same if the limb had been 
laid horizontally in bed without dressings or apparatus of any kind. 

S me have attempted to remedy this serious objection to ti 
ings by first applying adhesive plaster in the form of a lock strap, and 
in various other ingenious ways, above and below the fragment-. I have 
seen this done repeatedly at Bellevue, and my reported cast - furnish 

i Wy 

■■. Bluckrnan. Nashvill< 
May, 



560 FRACTURES OF THE PATELLA. 

quite a Dumber of examples; but, in almost every case, the straps soon 
became painful and had to be removed, and this required the opening of 
the plaster splint or its entire removal. In one of the cases (33) reported 
by me, the adhesive strips held in place by elastic bands caused such 
excessive pain as demanded the use of hypodermic injections of mor- 
phine repeatedly, and it resulted in an almost complete paralysis of the 
extensor muscles of the foot, which continued many months after the 
treatment was suspended; yet from all this there was no appreciable gain, 
inasmuch as the fragments united by ligament with the usual amount of 
separation. Indeed, so far as the position of the fragments is concerned, 
the dressings had only proved mischievous by thrusting one of the 
fragments laterally. 

Plaster of Paris is of all the forms of immovable dressings the worst, 
because it is the heaviest ; but of them all it must be said that they are 
unnecessarily cumbrous as a form of portative apparatus ; they are to 
some extent dangerous, especially in the hands of inexperienced sur- 
geons ; they are inefficient as means of approximating the fragments ; 
they actually serve but one single purpose, namely, to keep the limb 
straight, and this they do too effectually in many cases, causing an un- 
necessary degree of passive anchylosis. The limb can be maintained in 
a straight position by a much simpler and lighter dressing than a plaster- 
of-Paris splint, and by means which permit it to be daily examined and 
the condition of the fragments noted and corrected, and which will allow 
slight passive motion occasionally to the knee-joint; a practice which has 
been found in my experience perfectly safe, and useful in some measure, 
so far as the anchylosis is concerned. 

In short, to apply the plaster of Paris, and permit the patient to go 
about on crutches, as is generally recommended by its advocates, is to 
abandon, practically, every acknowledged indication of treatment, except 
straightening the limb and securing immobility at the knee-joint. 

The Author s Method of Treatment. — The limb being placed extended, 
with the foot elevated about six or eight inches, a long splint is applied 
to the back of the thigh and leg. This splint may be made of leather, of 
gum-shellac cloth (not felt), or of any other material having the neces- 
sary qualities of firmness, lightness, and plasticity, so that it can be 
properly moulded to the limb. Of late I have preferred the gum-shellac 
cloth, as possessing in a greater degree the necessary qualities than either 
of the others. The splint should be long enough to extend from above 
the middle of the thigh to two or three inches above the heel. Its width 
should be sufficient to inclose the posterior semi-diameter of the leg and 
thigh. It should be placed in hot water, and then moulded to the back 
of the limb : only that it is rather better not to fit it accurately to the 
popliteal space, in order that a small amount of cotton-batting may be 
placed between the splint and the skin. 

The splint should then be removed ; and, if made of shellac cloth, in 
a few minutes it will be sufficiently hard to retain its form. It is now 
covered completely with a firm cotton or woollen sack, and the sack 
stitched along the back of the splint. The splint having been curved to 
fit the circumference of the limb, the sack must hang loose across the 
concave surface of the splint, so that the limb may be allowed to fall 



FRACTURES OF THE PATELLA. 



561 



back to the splint, but the ends of the sack may be drawn and stitched 
tightly. 

One object of the covering is to furnish a protection to the skin against 
the splint; but the chief object is to supply a basis to which the bandage, 
which is to inclose the limb and splint, may be stitched. 

The splint must be applied while the limb is in the position already 
described, a small wad of cotton-batting having been placed in the ham. 
A roller, made of unglazecl cotton cloth, is then turned around the leg 
and splint to within about three inches of the knee, and another from 
the upper end of the splint over the splint and thigh to* within three inches 
of the knee. While an assistant approximates the fragments with his 

Fig. 223. 




The Author's m< 



■ dressing. — (The final turns of the roller, in the front of the 
knee, are not shown in the woodcut.) 



fingers, the surgeon makes two or three turns with a third roller around 
the limb and splint, close above the knee; after which the roller descends 
below the knee, and an equal number of circular turns are made close 
below the lower fragment of the patella ; and finally, a succession of 
oblique and circular turns are made above and below the fragments, 
which turns are to approach each other in front until the whole of the 
patella is covered — the last turns being again circular. The dressing 
now being completed, the rollers are carefully stitched to the cover of 
the splint through its whole length, on both sides; and the limb is left 
supported in the elevated position by a suspending apparatus, or by some 
other mode which will insure its maintenance in this position. 

I have been thus particular in my description because all of my readers 
may not have had experience in the application of bandages, and because 
to many of the details I attach importance. A few words of explana- 
tion of some of these points may not be amiss. 

The cotton cloth roller is preferred, especially for the purpose of 
approximating the fragments, because, if unglazed, it yields a little, and 
adapts itself smoothly to the skin, even sinking down a little just above 
and below the patella, thus rendering it Less liable to slide over. Re- 
versed turns are omitted altogether, because they cause sharp cords 
where they are folded, and sometimes produce painful constrictions and 
excoriation-. Adhesive strips, recommended by me in the first edition 
of this work, I have long since- laid aside. They are just as liable to 
slide, they are apt to cu1 at their free margins, and they have to be 



562 FRACTURES OF THE PATELLA. 

raised up from time to time to be tightened, and they cannot be stitched 
and thus permanently secured to the cover of the splint. No pads 
above and below the knee are recommended, because they are apt to 
become displaced, and if they remain in place they no more effectually 
press the fragments together than does the cotton roller. No pad is 
placed in front of the patella, because the last turns of the roller press 
back the fragments as effectually as a pad. Care must be taken when 
the roller is applied and the fragments are approximated, that the loose 
skin in front of the patella is not pressed between the fragments. No 
lotions must be applied, to saturate the dressings. They render the skin 
more liable to excoriations, and they are in no way useful. 

All that remains to be clone is easily said. On the second or third day 
the swelling of the knee will be found, probably, to have subsided some- 
what, and the oblique turns of the bandage from above and below the pa- 
tella will need to be tightened. This will be done by over-stitching, with 
strong thread, the oblique turns ; taking care to do this on both sides 
and so far back that the doubling of the cloth will not be over the sides 
of the exposed portions of the limb. The same thing may be required 
to be done every day, or every second or third day, for two or four 
weeks. Meanwhile it will generally be found — for the position of the 
fragments can always be felt — that the space between them has not been 
increased, and in most cases that it has sensibly diminished from the day 
of their first adjustment. 

At the end of about four weeks the apparatus should be removed care- 
fully. It is now observed, generally, that the knee is pretty stiff, and 
that the upper fragment cannot without considerable force be displaced 
in any direction. It is anchylosed, and there is very little danger that 
it will thereafter draw up further, and it is not probable that any appa- 
ratus will make it descend. But as a matter of safety, an assistant 
should now press the upper fragment gently downwards while the sur- 
geon flexes the knee very slightly, so as to diminish its stiffness. He 
ought, in doing this, never to cause pain or to use any degree of force. 

The splint is then to be reapplied in the same manner as before. 
Daily, thereafter, the splint should be removed with the same care, and 
the limb gently flexed. In the meanwhile the patient may go about 
upon crutches if he chooses. 

In six or eight weeks the bond of union may be considered completed, 
and the patient may be dismissed from the immediate care of the sur- 
geon, but not until he has been fully informed of the danger of a rupture 
of the new ligament, and has been provided with the means of protection 
as far as possible. He must be taught that for the next three or four 
months this danger is great; and that any sudden flexion of the limb may 
cause it; and, indeed, that it may be caused by simple muscular action, 
when the limb is not flexed. During this period he should walk only 
upon crutches, and the knee-joint should be constantly supported, unless 
he is completely at rest. 

The knee-caps usually furnished for this purpose are wholly unreliable. 
They allow the knee to bend too freely. Indeed, nothing but an inflexi- 
ble splint can insure safety ; and the same splint employed in the treat- 
ment, reduced one-half in length and secured by straps and buckles, is 
the best I have yet employed. 



FRACTUBES OF THE PATELLA. 



563 



Under no circumstances, in my opinion, is the surgeon justified in 
attempting to overcome the anchylosis by force, either with or without 
an anaesthetic. The chances are more than equal that he would substi- 
tute a ruptured ligament and an ununited patella for an anchylosed knee. 
I have been informed that this accident actually occurred at one of our 
city hospitals a few years ago, in the presence of a class of students. In 
time, and generally within a year or two, the anchylosis will disappear 
wholly under careful and moderate use of the limb. 

It will be seen that I no longer recommend the wooden inclined plane 
(Fig. 224) in all cases, as I have done in my earlier editions. The prin- 
ciple of its construction is correct, and the results have been satisfactorv, 
but it is unnecessarily cumbrous for a majority of recent and primarv 
accidents, and I reserve it now only for exceptional cases, such, for ex- 
ample, as those in which the separation is very great, or the inflammation 
and swelling are unusual. 

Fig. 224. 




The author's wooden inclined plane. To be used only in exceptional cases. 

Mr. Hutchinson, of London, has of late omitted to elevate the foot in 
the treatment of this fracture, and he thinks that the fragments are 
maintained in apposition with quite as much ease. 1 I cannot agree with 
him that nothing is ever gained by the elevation of the foot. On the 
contrary, in the treatment of a certain proportion of cases this position 
will be found essential to the best success, while in others it may be of 
little consequence whether the foot is elevated or not. 

The dressing and apparatus employed by Wood, of King's College 
Hospital, are very similar to my own wooden inclined plane, but, as will 
•n by the accompanying drawing, the splint is only five or six 
inches wide. Dr. Wood has substituted hooks for the notches. 2 

I will add now. although somewhat out of place, what that distin- 
guished surgeon, Corradi, of Bologna, has said on the subject of fibrous 
and bony union : 3 



1 Hutchinson. London Hosp. Reports, vol. xi. 2 Fergusson's Surgery, p. :)'»7. 

3 Delia Chirunria in Italia, dagli ultimi anni del Becolo bcotso flno al presente. 
Commentario di Alfonso Corradi. p. 216. (A concour prize essay, approved by the 
Med. Chir. 8oc. of Bologna. An. 1870.) The author refers to a' letter written' and 
published by Albertis in defence of Andrea Veronica; being a dissertation on the 
fracture of the patella, printed at Macerata in 1695. 



564 FRACTURES OF THE PATELLA. 

"Long before Ledeau and Pott, a Venetian surgeon, Pietro de Al- 
bertis, had made the observation that it was not necessary to the freedom 
of ordina?'!/ motion that a perfect union of the fracture of the patella 
should take place. 

"Hajani, from his own experience, was convinced that the danger of 
anchylosis and lameness was diminished by adopting no other means 
than the simple and natural situation of the parts, after having at first 
applied emollient or resolvent remedies," etc.; enjoining also early 
passive motion. "These views of Flajani were corroborated by Man- 
zotti " (Dissert, on Frac. of Patella, Milan, 1700), "and subsequently 
confirmed by modern surgeons, particularly by Velpeau. It is proper 
to point to the fact that the Roman professor, in the same way as Pott, 

Fig. 225. 




Wood's apparatus. 

abandoned apparatus, not, as some one has strangely asserted, for the 
purpose of increasing the separation of the fragments, but because he 
regarded position alone as sufficiently efficacious in the approximation 
of the fragments, but when these fragments are very much separated, 
position is not always efficient, nor are we much aided by apparatus, 
even although we employ the best." 

Treatment of a Rupture of the New Ligament. — I now come to con- 
sider briefly the treatment of a rupture of the newly formed ligament, 
called sometimes, improperly, a refracture. 

In all cases the patient should, as soon as possible, be subjected to the 
same plan as I have recommended for original fractures, but with smaller 
hope of a reunion. It is here when the separation is great, and in old 
cases of ununited fracture, that I could justify the use of Malgaigne's 
hooks ; but of their value even in these cases, I am not prepared to speak 
confidently. 

In employing Malgaigne's hooks the lower hooks are made to overlap, 
or grasp the lower margin of the lower fragment, and the upper hooks 
are projected forcibly into the top and front of the upper fragment. The 
upper hooks are therefore quite apt to loosen and slide. 

The time always arrives, according to my experience, both in primary 
fractures and secondary accidents or ruptures of the new ligament, when 
supporting and retentive apparatus is worse than useless. The period is 
within five months after the original accident, and within about the same 
period after the secondary accident. 

A reference to some of the cases I have reported, and especially to 



FRACTURES OF THE PATELLA., 565 

that of Assistant Surgeon Myers, of the United States Navy (case 40), 
will illustrate the importance of removing all support after a time, and 
teaching the muscles to rely upon themselves alone. Under proper and 
free use of the limb, aided by friction, electricity, etc., the muscles will 
become developed in size and strength, and through their remaining 
attachments to the sides and front of the leg, below the knee, will give 
to the patient often a very useful limb. The case is as follows : 

Assistant surgeon T. D. Myers, ret. 29, broke his right patella May 
19, 1874. when returning from the U. S. ship Kearsage, from mus- 
cular action in attempting to save himself from a fall. The fracture 
was transverse, and below the middle — at the upper end of the lower 
fourth. The fragments at once separated fully four and a half inches. 
Surgeon Bloodgood in charge. May 21st he was sent to the hospital at 
Yokohama. A long posterior splint was applied and the fragments 
secured with a figure-of-8 bandage. May 24th, Lausdale's apparatus 
was applied. This was worn five days, when it was found to have 
caused a slight ulceration above the upper fragment, and it was removed. 
A straight splint, secured at the knee by adhesive strips, was substituted, 
and kept on several weeks ; and soon after he began to walk, the frag- 
ments being united by a ligament one-half an inch in length on the inside, 
and one-quarter of an inch on the outside. 

August 2, 1874, seventy-five days after the first injury, and not 
long after he began to walk, he slipped and ruptured the ligament 
from muscular action. He was still in the hospital at Yokohama. 
A plastcr-of-Paris splint was now applied, which was renewed once in 
about eight days, and finally removed at the end of eight weeks. While 
this splint was on the limb he was allowed to go about on crutches. 
On removal it was found that no union of any kind had taken place. 
From this time forwards, a period of over five months and two weeks, 
he supported the limb with a leather splint, and walked about on 
crutches or with a cane. He consulted me March 17, 1875. I found 
the fragments separated four and a half inches, with very little motion 
at the knee-joint. Could not detect any bond of union. I advised the 
removal of the leather splint, and daily use of the limb by passive 
motion and active exercise in walking, also electricity, shampooing, etc. 

In a letter from him, dated May 23, 1875, he says: " Since consul t- 
ing you, March 17, 1875, I have steadily pursued the plan of treatment 
suggested by you."' etc. "The functions of the limb have gradually 
returned til] now I am able to walk very well, with very little or no 
limping/ 1 . . . "The atrophy of the muscles is gradually disappearing." 
. . . And In- concludes with expressions of gratitude for the happy 
result of the change in the mode of treatment. 

mpound <iml otherwise Complicated Fraetures. — Post, of New 
York, has reported three cases of* compound fracture of the patella ex- 
tending into the knee-joint, brought to a successful termination. 1 

In ;i case mentioned by Eve, of Augusta, occasioned by the kick of a 
horse, and in which amputation became accessary on the tenth day, 
••the knee-joint was found filled with dark grumous blood: n portion of 

1 P >rk Journ. of Med., vo\. ii., flrsl series, p. -'S7. 



566 f FRACTURES OF THE TIBIA. 

the cartilage of the internal condyle of the os femoris was chipped off, 
and the patella broken into a number of fragments." 1 

Levitt, of Michigan, has related a case of fracture in a lad set. 16, 
produced by striking his knee against a piece of timber, which resulted 
in suppuration of the knee-joint, but from which he finally recovered 
with the perfect use of the limb. The fracture of the patella was 
oblique, traversing only its upper and outer margin, and it was never 
much displaced. 2 

Dr. Levergood, of Pennsylvania, has reported a similar case, in which 
it became necessary to open the joint freely, yet it was followed by an 
excellent recovery, only a slight anchylosis remaining at the knee-joint. 3 

Dr. E. Mason has reported a case in which considerable anchylosis 
resulted from the plaster-of-Paris treatment. A refracture occurred, 
and although no blow was inflicted directly upon the knee, the adhesions 
which had ensued upon the previous fracture had so united the skin and 
subjacent tissues that the soft parts gave way with the bone, opening 
the joint freely. Extensive suppuration ensued and the patient died. 4 

Thomas A. Gallagher, set. 17, fell, May 24, 1880, thirty feet, striking 
with his right knee upon a rock, and breaking the right patella at its 
lower and outer third into several fragments — the wound communicating 
with the joint. He was placed immediately under my charge, and the 
limb was laid at rest in the horizontal position. No bandages or other 
restraints were employed. On about the fifth day suppuration occurred 
in the joint, and the limb became greatly swollen. I opened the joint 
freely, removed all of the small fragments, and made a counter-opening, 
through which a large drainage-tube was passed. Hot water fomenta- 
tions were applied to the whole limb, and the knee-joint was daily washed 
thoroughly with a weak solution of carbolic acid. The inflammation and 
suppuration began to subside from this date, and on the first day of July, 
thirty-seven days after the accident, he was walking on crutches, the 
wounds having nearly closed, the joint being free from inflammation, and 
sufficient motion remaining to render it probable that the functions of 
the joint will be completely restored. 



CHAPTER XXXI. 

FRACTURES OF THE TIBIA. 

Development of the Tibia. — The tibia is formed, usually, from three 
centres of ossification — one for the shaft, and one for either extremity. 
Ossification commences in the shaft at or about the fifth week of foetal 
life. In the upper epiphysis it appears at birth, and unites with the 

1 Eve, Southern Med. and Surg. Journ., 1848; also Boston Med. Journ., vol. xxvii. 
p. 127. 

2 Lewitt, Medical Independent, Sept. 1856. 

3 Levergood, Amer. Journ. Med. Sci., Jan. 1860. 
* Mason, N. Y. Journ. Med., April, 1875, p. 416. 



FRACTURES OF THE TIBIA. 



567 



Fig. 226. 



shaft at about the twenty-fifth year. Generally it forms the tubercle, 
but occasionally the tubercle has a distinct point of ossification. The 
lower epiphysis commences to ossify during the second year, and unites 
with the shaft at about the twentieth year. The malleolus interims is 
occasionally formed from an independent centre. 

Etiology of Fractures of the Tibia. — Fractures of the tibia alone are, 
in a large majority of cases, produced by direct blows, such as the kick 
of a horse, or a blow from a stick of wood ; in one instance I have seen 
it broken by a kick from a Dutchman's boot. It is occasionally broken 
by a fall upon the foot, the force of the impulse being expended before 
the fibula gives away, but almost always the fibula breaks at the same 
moment, or immediately after the fracture has taken place in the tibia. 

Heydenreich relates the case of a man 42 years old, in a Bordeaux 
hospital, whose tibia was broken above the tubercle in an attempt to 
straighten an anchylosed knee. The patient died on the eighth day, 
from a haemorrhage caused by the pressure of the displaced fragment 
upon the popliteal artery. 

Dr. Proudfoot. of New York, has reported an example of fracture of 
the tibia in utero, produced in the sixth month of pregnancy, by violent 
pressure upon the abdomen. 1 

Pathology. Division, etc. — In an analysis of twenty-seven fractures of 
the tibia, not including fractures of the malleoli, six were found to have 
occurred in the upper third, eleven in the middle third, 
and eight in the lower third. Six of the twenty-seven 
are known to have been transverse, or only slightly 
oblique. It is probable, also, that several of the remain- 
der were transverse. In this respect, therefore, fractures 
of the tibia alone will be found to differ materially from 
fractures of the tibia and fibula; but it is only in accord- 
ance with the general observation that indirect blows . 
produce almost constantly oblique fractures, and direct 
blows somewhat more frequently transverse. 

According to Heydenreich 2 fractures of the upper 
third of the tibia occur most often between the 30th 
and 50th years of life, and he has not found a case re- 
corded in a person under 22 years of age. I have myself. 
also, noted the fact that fractures above the tubercle arc 
most common in old persons. Fractures of the tibia 
extending into the knee-joint are in most eases coin- 
pound, or othe ionsly complicated as to render 
amputation necessary. 

The malleolus interim- is broken frequently at the 

same time that the ankle-joint is dislocated, mid this 

lent will be considered in that connection, and in 

connection with fractures of tic- lower end of the 

fibula. 

Epiphyses. — We have already men- 
tioned that Madame Lachapelle has reported a ease of 




| men t of 
the tibia. From 

Gray.) 



1 Proudfoot, B -• :. Hed. and Surg. Journ., vol. xxxv. | 
York Journ. 

2 Heydenreich, Prac I I i tibia, th. de Paris, 1-77. No. 43. 



568 FRACTUBES OF THE TIBIA. 

separation of the upper epiphysis of the tibia, and of the lower epiphysis 
of the femur, occasioned by pulling at the foot during birth. 

Blasius 1 relates the case of a boy, 16 years of age, in whom the upper 
epiphysis was separated completely from the shaft by having his foot 
caught in machinery. M. Peuleve 2 has in his possession a similar speci- 
men obtained from a lad 6 years of age. The accident had been caused 
by the leg being caught in the revolving wheel of a carriage, and the 
severity of the injury was such that it became necessary to amputate. 
Fischer and Hirschfeld 3 have observed the same lesion in a boy 17 
years old. 

Dr. Voss, of New York, has seen a separation of the lower epiphysis 
in a boy 14 years old, who in falling had caught his foot between two 
blocks of wood. The upper fragment protruded through the skin. Re- 
duction was effected, but subsequently a portion of the epiphysis became 
necrosed and was removed. He finally recovered with a useful joint. 4 

Dr. R. W. Smith has reported a similar case in a boy 16 years of 
age. and which, having occurred six months before, remained unreduced. 
The lower end of the shaft was displaced forwards. Richard Quain 
records one other example, in a lad 17 years old, which was easily 
reduced and maintained in position. 5 

N. A. Powell, 6 of Edgar, Canada, has reported an example of con- 
genital displacement of the upper epiphysis of both tibiae in an other- 
wise healthy girl. Reduction was easily effected, but was with difficulty 
maintained. When about 14 months old, however, the epiphyses were 
kept in place by means of plaster-of-Paris splints with which she was 
permitted to walk about, and a perfect union was finally obtained. 

Inasmuch as the tubercle has sometimes a separate point of ossification 
it may occasionally be detached, and the accident will then be distin- 
guished from a fracture of the ligamentum patellae, by the presence of a 
hard and movable body and by crepitus. 

Prognosis. — No shortening can occur in this fracture unless one or 
both ends of the fibula are displaced, a complication which I have noticed 
in two instances, but in neither case did the shortening exceed one- 
quarter of an inch ; unless, indeed, the fibula bends and remains bent, or 
the comminution and direction of the fracture are such at either end as to 
allow the femur or the astragalus to become impacted. I have never 
recognized either of these conditions. 

Occasionally the upper fragment has been slightly displaced forwards. 
With these exceptions, and one other of delayed union which I shall 
presently mention, this bone, in my experience, has been found to unite 
promptly and without any appreciable deformity. Other surgeons have 
noticed occasionally that the upper end of the lower fragment has become 
displaced toward the fibula. 

1 Blasius, Poncet, Nouv. Die. M£d. et de Chir., t. 19, p. 513. 

2 Peuleve. Bull. Soc. Anat, 1865. 

3 Berlin. Klin. Woch., 1865, II. 10. (Poinsot, op. cit.) 
1 Voss, X. V. Journ. Med., Nov. 1865, p. 133. 

\ York York Journ. Med., June, 1868; from British Med. Journ., Aug. 31, 
1867. 

* ; 1'. .well, Canada Lancet. July 1, 1881. 



FRACTURES OF THE TIBIA. 569 

Delayed union has been observed pretty frequently in fractures of the 
upper third of the tibia, of which circumstance M. Duplay, according to 
a reference to one of his clinical lectures, contained in the Lancet, May 
18. 1878. makes the following observations : 

"In many of these cases there is no constitutional vice to which it can 
be attributed, and the usual local causes of non-union are absent. It 
has been stated that fractures above the entrance of the nutrient artery, 
which is directed downwards, unite less readily than those below it on 
account of their relation to the blood supply of the bone. But the upper 
end of the tibia is the most vascular part of the whole bone, and its 
nutrition may. therefore, be presumed to be in a very active condition.'" 
He regards, however, this very vascularity of the bone as the cause of 
the difficulty of union, as. when fractured, the great number of torn ves- 
sels pour out an unusually large quantity of blood between and around 
the broken ends of the bone, which coagulates, and thus impedes or 
altogether prevents the thorough organization and ossification of the 
callus. He states that in these cases he has met with distinct evidence 
of this extensive effusion of blood. 

I have met with examples of delayed union in this portion of the bone, 
of some of which I shall hereafter speak more particularly. 

Dr. Donne, of Louisville, has reported an example of delayed union 
in a simple transverse fracture of the upper end of the tibia. The man 
was intemperate. Ten weeks after the accident no union had occurred. 
Dr. Donne introduced a seton, and in about six weeks the fragments 
were firm. 1 

Muhlenberg, in his tables comprising 656 examples of delayed and 
non-union of long bones, records 81 of the tibia alone : of which number 
2 were cured by friction, 7 by mechanical appliances, 3 by seton, 11 by 
tion, and 15 by drilling. 2 

If the fracture extends into either the knee- or ankle-joint, the danger 
of anchylosis is imminent, yet experience has shown that it may some- 
times be avoided. 

When the malleolus is broken off. it generally becomes slightly dis- 
placed downwards, and in this position a complete bony or ligamentous 
union of the fragments generally take- place. 

Treatnu nt. — The tendency to displacement, in a fracture of the shaft 

of the tibia, i- usually so slight, if it exist.- at all. that simple dressings, 

light splints of leather, felt, or binder'.- board, with rest in the horizontal 

e upon a pillow, fulfil nearly all the indications which are present. 

following case- will illustrate the usual coarse of these accidents: 

Mrs. W. fell, Oct. 19, 1848, Btriking on her right knee, breaking the 

tibia transversely just below the tuberosity. The fall was the result of a 

level ground, and was attended with only Blight bruising of 

thai on attempting to rise«he discovered what 

hail happened, the bone projecting very distinctly, and -lie pushed and 

pulled it into place with her own hand-. 

I dressed the limb by laying it upon a pillow, outside of which were 

1 nne, Amer. • , Sci ,to1. x.wii. p. 524 : from Western Journ. Med. 

and Surg., Aug. 1841. 
- Muhlenberg, Agnew'a Surg., dp. cit., vol. ii. ) 



570 FRACTUKES OF THE TIBIA. 

placed two broad deal splints, tying the whole snugly together with 
several strips of bandage.. At a later period the leg and thigh were laid 
over a double-inclined plane. At the end of six weeks all dressings were 
removed, and the fragments were found to have united firmly, and so 
perfectly that the point of fracture could not be traced. 

Peter Hamil, set. 29, was admitted into the Buffalo Hospital of the 
Sisters of Charity, Aug. 31, 1849, with an injury to his left leg, which 
had occurred two days before. A young surgeon had examined the limb, 
and thought the femur was broken just above the joint. He had applied 
a roller from the toes to the thigh ; and to the thigh were applied lateral 
splints. These dressings were on the limb at the time of his admission, 
and were not removed until the next day. I could not then discover any 
fracture or displacement, and the dressings were discontinued, the limb 
being merely laid upon pillows. 

Oct. 4, when examining the limk, I detected a slipping sensation, like 
that produced in a false joint, through the upper end of the tibia, and I 
now easily understood what had been mistaken for a fracture of the 
femur. It was a transverse fracture through the upper end of the tibia, 
and without displacement. 

No splints were afterward applied, and on the 25th of November, 
three months after admission, he was dismissed, the motion between the 
fragments having ceased, but the knee still remaining quite stiff. 

The presence of inflammation, with other complications, may, how- 
ever, occasionally render the treatment more difficult and the results less 
satisfactory. 

John Mahan, set. 39, admitted to the Buffalo Hospital of the Sisters 
of Charity, Feb. 16, 1853, with a compound fracture of the right tibia, 
near the middle of the leg. The bone was broken by a kick. I found 
the limb swollen and painful, and I laid it carefully over a double-inclined 
plane, and directed cold w T ater irrigations ; I also directed morphia in 
full doses. The inflammation for several days threatened the complete 
loss of his limb. On the tenth day the distal end of the upper frag- 
ment was projecting in front of the lower, and I depressed the angle of 
the splint and made moderate pressure upon the upper fragment. On 
the twentieth day the fragments were bent backwards, and I placed a 
compress behind. On the thirty-seventh day w T e took the limb from the 
.inclined plane, and trusted alone to side-splints. On the forty-fifth day 
Ave removed all dressings. The fragments had not united. The limb 
was then laid upon a pillow, and six days later a firm gutta-percha splint 
was applied for the purpose of steadying the bone, but the splint was 
removed daily in order that the leg might be bathed and rubbed. He 
was allowed to sit up. On the fifty-ninth day motion could still be per- 
ceived between the fragments, and he was directed to use crutches. On 
the ninety-third day the union was found to be firm, the upper fragment 
remaining slightly displaced forwards. 

In case the fracture extends into the knee-joint, it is best to lay the 
limb upon pillows in a nicely cushioned box, and nearly straight. No 
extension or counter-extension is necessary here any more than in other 
fractures of the tibia alone, nor are lateral splints or rollers necessary 
or proper at first as a general rule ; but especial attention should con- 



FRACTURES OF THE TIBIA. 571 

stantly be given to the prevention of inflammation, and of subsequent 
anchylosis. The omission to employ splints in a case of this kind was 
charged against a surgeon in Vermont as evidence of malpractice. I 
am happy to say, however, that, in this particular case, he was sustained 
by the testimony of the medical men and by the verdict of the jury : 
but the attempt which the reporter has made to defend this as a univer- 
sal practice in fractures of the leg, or of the tibia alone, is unfortunate, 
and evinces a lack of practical experience. 1 

Whatever position is adopted, and whatever means of support or 
retention are employed, if bandages or splints are applied tightly or 
injudiciously, great suffering and irreparable mischief to the knee-joint 
may be the consecpience. 

A man. aet. 23, entered the Pennsylvania Hospital, July 18, 1839, 
with an oblique fracture through the head of the tibia. A physician 
had applied a bandage and splint to the leg, and sent him twenty miles 
to the city. and. on examination after his arrival, the whole limb as high 
as the groin was much swollen, red, and excessively painful. The knee- 
joint was distended and very tender. All dressings were immediately 
removed, and the limb laid in a fracture-box slightly elevated at the foot; 
cool lotions were applied, and the patient was freely bled, both from the 
arm and by the application of leeches. The limb was kept in this posi- 
tion about six weeks, and at the end of two or three weeks more he was 
dismissed, cured. Dr. Norris, who was the hospital surgeon in attend- 
ance, has, in his report of the case, very properly taken this occasion to 
warn surgeons of the danger of excessive bandaging and splinting in 
this kind of fracture, as well as in all other fractures of the lower ex- 
tremities. 2 

Fractures of the malleolus, unaccompanied by any other accident, 
demand only that the limb should be laid upon its outer or fibular side, 
with the foot so supported that it shall incline inwards toward the tibia. 
In this simple disposition of the limb we have done all that can be done 
by any mechanical contrivance toward approaching the lower fragment 
to the shaft from which it has been broken. 

Treatment of Delayed Union. — If improving the general condition 
of the patient by allowing him to go about with or without splints, or 
frictions of the ununited surfaces, do not succeed, we may be obliged to 
resort to other, strictly surgical expedients. It has already been stated 
that Dr. Donne, of Louisville, resorted successfully to the seton. I have 
succeeded by other means. 

Mr. H. Lichstenstein, set. 40, broke his left tibia Aug. 6, 1866, by 
twisting his log violently in the upper third. There was only a slight 
forward displacement of the lower fragment. His surgeon dressed it 
with Swinburne's extension apparatus, without side-splints. I was called 
• him, in consultation, sixteen weeks after the accidenl occurred, and 
found the fragments perfectly movable. He had not yet left his bed. I 
advised a firm gutta-percha splinl to be moulded to the back of his thigh 
and leg, and that he should go about on crutches. My advice was fol- 
lowed, and in six weeks the bone was united and firm. 

1 Boston Med. Journ.,vol. liv. p. 1, March, 1866 

- v ::'-. Amer. Journ. of Med. 8ci., vol. xaciii. p. 291. 



572 



FRACTURES OF THE FIBULA. 



Iii the case of John J. Blair, of Brooklyn, with a transverse fracture 
just below the tubercle of the tibia, the union was delayed many months. 
He placed himself under my charge at St. Elizabeth's Hospital, in this 
city, and as he had been walking for some time, and his health was 
good. I perforated the bone with Brainard's drill several times, and, bind- 
ing a firm splint upon the back of his thigh and leg, he was laid in bed. 
After the first week I pushed an ordinary shawl-pin between the frag- 
ments, and left it in place three days. This was repeated several times, 
and at the end of a few weeks union was complete. 



CHAPTER XXXII. 



FRACTURES OF THE FIBULA. 



Development of the Fibula. — The fibula is formed from three centres 
of ossification — one for the shaft, and one for each extremity. Bone 
begins to be deposited in the shaft at about the sixth 
Fig. 227. week of foetal life, in the lower extremity during the 

second year, and in the upper extremity during the 
fourth year. The lower epiphysis unites with the shaft 
about the twentieth year, and the upper about the 
twenty-fifth year. 

Epiphyseal Separations. — Stimson relates that " in 
April, 1883, a child, about two years old, was run over 
by a street-car and brought to the Presbyterian Hospital. 
In addition to other wounds, which were promptly fatal, 
there was a lacerated wound on the outer side of the 
right leg exposing the upper end of the fibula and open- 
ing the knee-joint. The epiphysis of the fibula was 
completely detached from the shaft and from the tibia, 
and remained attached to the external lateral ligament 
and the tendon of the biceps * r there was also an incom- 
plete fracture of the shaft of the fibula three-fourths of 
an inch below the epiphyseal line, and the intermediate 
portion was denuded of its periosteum, which remained 
I attached to the epiphysis." 1 

I \ I am unable to refer to any other example of separa- 

PW tion of either the upper or lower epiphysis of the fibula. 

^W/ Causes of Fracture. — In a record of forty-eight cases 

I have been able to ascertain the cause satisfactorily in 
thirty-two, of which number six were the results of falls 
directly upon the bottom of the foot, but which were 
probably accompanied by a twist of the foot, eleven of 
a slip of the foot in walking on level ground or on ground only slightly 
irregular, and fifteen of direct blows. 



Development of 
the fibula. (From 
Bray. 



1 Stimson, op. cit., p. 586. 



FRACTURES OF THE FIBULA. 573 

I shall here take the liberty of quoting the careful studies and observa- 
tions of Poinsot : 

" Muscular contraction is sometimes the cause of fracture of the fibula. 
In this case, the superior extremity detaches itself from the rest of the 
bone. This variety of fracture, very rare however, was noted as early 
as 1854. by Professor Hergott, of Strasburg ; l at the same time, two 
practitioners of the upper Rhine, Weber and Miiller, reported each an 
observation of the same kind. Brand, in 1877, reported a case of frac- 
ture of the head of the fibula which complicated a dislocation of the leg 
forwards. 2 Similar facts were recently published by Messrs. Duplay, 
Perrin, and Terrier. 3 Hergott's patient, a woman fifty-two years old, 
fell ; throwing herself quickly backwards, she felt a crack in her left leg 
on which her body was resting. A slight tumefaction was discovered 
opposite the head of the fibula, as also a manifest crepitus, felt by the 
patient as well as by the doctor. The fracture in Weber's patient, and 
probably also in Terrier's, was produced in the same way. In Miiller's 
case, two young men were wrestling ; one of them, on the point of being 
thrown, made a violent effort ; but cried out so 'that his adversary let go; 
he did not fall, although he could not use his leg. Miiller recognized a 
fracture of the head of the fibula. Brand's patient was knocked down 
backwards by a cow on a pile of stones and wood. The leg, in M. Perrin's 
case was caught between the ground and a fallen horse. M. Duplay's 
patients, men of forty-eight and sixty years, had been caught, one by 
the shaft of a machine, the other by a transmission belt, and their bodies, 
drawn in a rapid movement, struck a neighboring wall repeatedly. The 
patients explained perfectly, that in the movements of rotation to which 
they had been subjected, their legs came in contact with the ceiling, so 
that the inferior right limb (where the arrachernent of the fibula existed) 
was -truck from outwards inwards, and consequently tended to bend vio- 
lently inwards. It seems to us that the mechanism admitted by Hergott 
can l»e applied to all the cases : the leg being slightly bent on the thigh, 
the biceps contracts with all its strength perpendicularly to the line ot 
the fibula, which breaks at its feeblest point. This mechanism, which 
cannot be contested in Hergott's, Weber's, and Miiller's cases, is equally 
admissible in Perrin's and Duplay's. One can well understand, that the 
upper part of the leg being fixed in slight flexion by contact with the 
ground or the ceiling, the biceps should act with more efficacy. As to 
Brand's case, it furnishes no details in reference to the mechanism of the 
lesion ; it seems, however, that Hergott's theory may well be applied 
to it." 4 

Pathology of the True Fractures. — In all of the fractures recorded by 
me which have been produced by falls upon the bottom of the foot, and 
in all except oik- produced by a slip of the foot, the accident was accom- 
panied by a partial dislocation of the ankle; the foot being Tinned out- 

1 Hergott, Gaz. Bfed. de Strasburg, is.",}, p. 344. 

2 Brand, Bayr. artzlichea Intell., 1877, No. 52, p. 543. 

3 Bull. 80c.de Chir., 18* 

* Poinsot, op. cit., p. 652. 'In Bciat. poplit. ext, dans frac. de 

l'ext. sup. du perone. Duplay. Prog. Bfed . Paris, 1880, viii. 2-',7. 



574 



FRACTURES OF THE FIBULA. 



Fig 



wards. In the one exceptional case mentioned, the dislocation may also 
ha vi' occurred, but the fact is not known. 

Both Malgaigne and Dupuytren have noticed a dislocation in the op- 
posite direction, or a turning of the foot inwards, more often than a 
turning outwards. I cannot think their observations were carefully 
made. 

Moreover, in at least ten of the fifteen fractures produced by direct 
blows, the tibia has been thrown more or less inwards, and consequently 
the foot has turned out. Occasionally the tibia slides a little forwards 
upon the astragalus. But this seldom happens as the primary accident ; 
it occurs later, perhaps within the first ten days after the accident, when 
the heel has been insufficiently supported. 

In thirty-seven examples the fracture of the fibula has taken place 
within from two to five inches of the lower end of the bone-. Three 
times the external malleolus was broken off, and eight 
times the internal malleolus. 

Five of the fractures occurring in consequence of 
direct Mows were compound, and one was also com- 
minuted. 

It will be seen, therefore, that the most frequent 
form of fracture of the fibula is that first described by 
Pott as follows : " This is the case when, by leaping or 
jumping, the fibula breaks in the weak part already 
mentioned ; that is, within two or three inches of its 
lower extremity. When this happens the inferior frac- 
tured end of the fibula falls inwards toward the tibia, 
that extremity of the bone which forms the outer ankle 
is turned somewhat outwards and upwards, and the tibia, 
having lost its proper support, and not being of itself 
capable of steadily preserving its true perpendicular 
bearing, is forced off from the astragalus inwards, by 
which means the weak bursal or common ligament of 
the joint is violently stretched, if not torn, and the 
strong ones, which fasten the tibia to the astragalus 
and os calcis, are always lacerated ; thus producing at 
the same time a perfect fracture and a partial dislocation, to which is 
sometimes added a wound in the integuments made by the bone at the 
inner ankle." * 

Maisonneuve 1 thinks he has established, by experiments upon the 
cadaver, that the fracture of the fibula at its lower extremity is caused not 
by forced abduction of the foot, but by violent outward rotation. While 
M. Tillaux, 2 by the same mode of experimentation, has reached a different 
conclusion. According to M. Tillaux, the first effect of the forced abduc- 
tion is to tear the internal lateral ligament, or to fracture the internal 
malleolus. The force, continuing to operate in the same direction, presses 
the astragalus against the external malleolus and tends to separate the 




Fracture of fibula 
near lower end. 



1 The Chirurgical Works of Percival Pott, F.R.S., Surgeon to St. Bartholomew's 
Bospital. First Amer. ed., 1819, p. 248. 
* Maisonneuve, Arch. Gen. de Med., fev. et avril, 1840. 
3 Tillaux, Anat. Top., Paris, 1877, pp. 1172-1175. 



FRACTURES OF THE FIBULA. 



575 



fibula from the tibia, and may so far rupture the inferior peroneo-tibial 
ligament as to cause a diastasis of the articulation : or a portion of the 
lower end of the tibia upon which the ligament is attached may be torn 
off: or. the diastasis not having taken place, the fibula may break above 
the peroneo-tibial ligament. To this fracture M. Tillaux gives the name 
"bi-malleolar by abduction.'" It is essentially the typical Pott's fracture, 
although it was not so described in all points by him. 

Fig. 229. 




Vertical and transverse section of the tibo-tarsal articulation. Right foot. (Tillaux.) 

In the forced movement of adduction, on the other hand, the external 
lateral ligament is first put upon the stretch, perhaps ruptured, or the 
external malleolus is torn off, sometimes at its summit, but most often 
at its base. In this case the fragment is not usually displaced, nor is 
the foot in any way deformed. It is a fracture by arrachement alone, 
and is not complicated with any other fracture. 

But the astragalus released by the rupture of the external lateral liga- 
ment, or of the malleolus externus, and continuing to press inwards upon 
the malleolus internus, finally causes a fracture of this latter also, at its 
This he calls the " bi-malleolar fracture by adduction." 

It may happen, also, that neither the external lateral ligament nor 
the malleolus externus having given away, the fibula will break above 
the inferior peroneo-tibial ligament, and, the force continuing to act, the 
h»wer end of the body of the tibia will be torn off in whole or in part. 
This he terms a "transverse supra-malleolar fracture." 



576 FRACTURES OF THE FIBULA. 

These observations made by Tillaux, like all similar observations made 
exclusively upon the cadaver, must be accepted, as applied to the living 
subject, with some degree of reserve, since they lack the conditions of 
rigidity of the muscles, with force and direction of impact which in a 
degree more or less contribute to the peculiar lesions in the latter. 

Prognosis. — Says Poinsot : l " The prognosis of fracture of the fibula 
(at its upper end) by arrachement is grave ; this is not due so much to the 
bony lesion, as to the consequent wounding of the external popliteal branch 
of the sciatic nerve. This wound is noted in all the observations men- 
tioned by me. In the case of Hergott's patient, flexion made the primary 
pain cease, but for two months and a half walking was impossible. Weber's 
patient experienced a permanent incomplete paralysis of the flexors of the 
foot ; in Midler's case, the calf remained painful for a long time. In Brand's 
case, there persisted for some time an incomplete paralysis of the muscles 
and a local anaesthesia of the integument, in the treatment of which the 
inducted currents had to be resorted to. In the two patients observed 
by M. Duplay, the one who survived exhibited, after the lapse of a year, 
a complete paralysis of the extensors of the foot and of the lateral 
peroneal muscles ; he could hardly take a few steps with crutches. In 
M. Perrin's patient, after a period of two months, the paralysis remained 
the same as on the first day. Finally, M. Terrier noticed in his patient 
violent pains in the dorsum of the foot with anaesthesia, from the be- 
ginning; but before long, these primary phenomena were succeeded by 
secondary accidents producing pain. The relations of the external 
peroneal nerve with the head of the fibula, the contour of which it follows 
before lodging into the interosseous space, explain the reason why it is 
frequently wounded under those conditions. Being torn by the bone at 
the time of the accident, that nerve may, afterwards, be included in the 
effusion which, later on, will constitute the callus." 

In a majority of cases, where the fibula has been broken from two to 
five inches above the lower end, the fragments have united inclined toward 
or resting against the tibia ; occasionally I have seen them displaced 
backwards or forwards. Once the fibula refused to unite altogether. 

The malleoli have generally united nearly or quite in place, but in two 
instances the external malleolus has been found displaced very much 
downwards. 

Of the compound fractures, two required amputation, one was treated 
by resection of the lower end of the tibia, and two died without any 
operation. Douglas has reported a case of compound dislocation with 
fracture of the fibula, which being reduced, he was able to save the limb, 
but not without much difficulty, and the ankle remained stiff. 2 Other 
surgeons have met with similar success, but I shall refer to this subject 
again under the head of compound dislocations. 

Of those which recovered, forty-six in number, twelve have been found 
to have more or less unnatural prominence of the internal malleolus, and 
in two of these the malleolus, or lower end of the tibia, projects very 

1 Poinsot, op. cit., p. 655. 

2 Boston Med. and Surg. Journ., vol. xxxiv. p. 336, from Southern Journ. of Med. 



FRACTURES OF THE FIBULA. 577 

much. In nearly all of these latter examples the foot appears somewhat 
inclined outwards. 

Generally the ankle-joint has remained stiff for some time after the 
bandages have been removed; and probably in all cases in which the 
accident was accompanied by a dislocation of the tibia. But this stiff- 
ness has usually disappeared after a few weeks or months. Twice I have 
noticed considerable stiffness after about six months ; three times after 
one year ; in one case after two years : and in one case after twenty 
years the ankle would occasionally swell, and become quite stiff. In one 
case it remained almost immovable after twenty years; and in a still 
more remarkable instance, I examined the limb thirty years after the 
accident, when the man was sixty-three years old, and although there 
existed no swelling or deformity, yet this leg was not as muscular as the 
other, and he declared that up to that time the ankle remained quite 
tender to the touch, and that occasionally it became painful. 

When I come to speak of dislocation of the ankle, I shall adopt the 
usual nomenclature, and shall name all those dislocations in which the 
tibia projects inwards from the foot, '-inward dislocations of the tibia;" 
yet I have some doubts as to the propriety of calling this a dislocation, 
either partial or complete. This accident seems to me to have been in 
general rather a lateral rotation of the foot, or of the astragalus, upon 
the lower articulating surfaces of the tibia and fibula. Of all the gin- 
glymoid joints, the ankle approaches most nearly in form to a ball-and- 
socket joint, in consequence especially of the marked prolongations of 
the malleolus interims and externus. In other ginglymoid articulations 
lateral displacements are not unfrequent, but lateral rotation can scarcely 
by any accident occur. Here, however, the reverse holds true ; lateral 
displacement is difficult, while lateral rotation is comparatively easy of 
accomplishment. 

The majority of cases which occur, involving a disturbance of the 
relative position of the ankle-joint surfaces, are, I am satisfied, of this 
latter character, viz., lateral rotations within the capsule, rather than 
true dislocations : and although the restoration of the joint surfaces to 
position is. in general, easily accomplished, yet in consequence of either 
a fracture of the fibula or malleolus internus, or of a rupture of the in- 
ternal lateral ligaments, it will generally happen that some deformity 
will remain. The fragments of the fibula will fall inwards toward the 
tibia, and the foot, unsupported by either its fibula or its internal liga- 
ments, will incline perceptibly outwards. Nor can this be wholly pre- 
vented, in most cases, by any mechanical contrivance. Indeed, it would 
be easy to demonstrate, as I have often done to my pupils, that even 
Dupuytren's splint, heretofore so much employed in this accident, must 
fail of success in a great majority of cases; since the subsequent de- 
formity is due less to the fracture of the fibula and its consequent dis- 
placement than to the loss of the internal Ligaments, which loss nature 
can seldom fully repair. As farther evidence of the correctness of tins 
view. I will -tare that in three of the examples in which I have found 
the fractured fibula united and resting against the tibia, the motions of 
the ankle-joint have been completely recovered. 

I do not here rd'ev to th in which ;i portion of the outer and 



578 



FRACTURES OF THE FIBULA. 



lower extremity of the tibia being also broken off obliquely, and more 
or less displaced, perhaps rotated upon its axis, the perfect approximation 
of the tibio-peroneal articulation becomes impossible. Such cases neces- 
sarily entail serious deformity. 

If. however, it were true that a fracture and displacement of the 
fibula is the sole or essential cause of the subsequent deformity, it would 
still be found often impracticable to avoid the maiming, since it would 
still remain impossible to lift the broken ends from the tibia, against 
which, or in the direction toward which, they are so prone to fall. In- 
version of the foot does not accomplish it, nor have I ever been able to 
make anything but the most trivial impression upon the upper end of 
the lower fragment by pressure upon the lower extremity of the fibula. 
I think too much confidence has been placed in the efficiency of 
"Dupuytren's splint." I believe, indeed, that this splint is, in many 
cases, a very appropriate means of support and retention after this acci- 
dent ; but I doubt whether it is able to accomplish all that its illustrious 
inventor proposed, and especially in those cases in which, the fibula 
being broken, and the internal lateral ligaments torn, the astragalus is 
disposed to glide backwards ; of which I have seen several examples, 
some of which have left a permanent and serious deformity, in the 
elongation of the heel and shortening of the foot in front of the tibia. 
It does not appear that either Pott or Dupuytren was aware of this 
form of displacement from this cause. 

Treatment. — Dupuytren's mode of dressing is essentially as follows : 
A pad, or long junk, made of a piece of cotton cloth, stuffed with 
cotton-batting, is constructed of sufficient length to extend from the con- 
dyles of the femur to a point just above the malleolus internus. This 
pad must be about five or six inches in width, and thicker 
by two or three inches at its lower than its upper end. 
This is to be laid upon the inside of the leg, with its base 
or thickest portion resting against the tibia just above the 
internal malleolus. Over this pad is to be placed a long 
firm splint, extending also from above the knee to three 
inches beyond the bottom of the foot. With a few turns 
of a roller the upper end of the splint must now be made 
fast to the knee, and with a second roller the lower 
end secured to the foot. The application of this last 
bandage requires, however, some care in its adjustment. 
Its purpose is simply to rotate the foot inwards, while at 
the same time the tibia is pressed outwards ; and to this 
end it must be applied in the form of a figure-of-8 over 
both splint and foot, embracing alternately the heel and 
the instep. In order to be effectual, it must be drawn 
pretty firmly, and no portion of the bandage must pass 
higher than the malleolus externus. In some surgical 
books I have seen this apparatus represented with a roller 
embracing the whole length of the leg ; and in others it 
is represented as encircling the limb two or three inches 
above the malleolus (Fig. 230) ; but it is evident that these modes of 
dressing must defeat the great object which Dupuytren had in view, 
namely, the throwing out of the upper end of the lower fragment. 



Fig. 230. 




htiu/ 



Dupuytren's 
splint, incor- 
rectly applied. 



FRACTURES OF THE FIBULA. 579 

When the limb is thus dressed, the knee may be flexed and the leg- 
laid upon its outside, supported by a pillow, or upon its inside, as in the 
accompanying engraving (Fig. 231). 

If it is only a fracture of the external malleolus, or if the fracture has 
occurred in the middle or upper third of the bone, this treatment is no 
longer appropriate, and it will generally be found sufficient to place the 
limb at rest for a few days upon a suitable cushion or upon a pillow. 

Of late years I have not employed Dupuytren's splint, and especially 
because I have met with several examples of backward displacement of 
the foot following fractures of the fibula, which Dupuytren's splint is not 
competent to prevent or to remedy. This subject will be considered 

Fig. 231. 




Dupuytren's splint as originally applied by himself. 

more fully in connection with forward luxations of the tibia at its lower 
end : but it is necessary to say here that this accident can be most cer- 
tainly avoided by employing the plaster of Paris or starch dressing; 
taking care in applying the dressing to secure a thorough inversion of 
the toes and foot, the same as in case the limb were dressed with Dupuy- 
tren's splint. Care must be taken, also, not to permit the bandages to 
press upon the limb above the malleolus externus. The same results may 
be attained by well-adjusted leather, felt, shellac, or gutta-percha splints, 
which inclose the heel as well as the sides and front of the limb. 

It is scarcely necessary to say that, since after the accident anchy- 
losis is so frequent, early and unremitting attention should be given to 
the establishment of passive motion in the joint. Indeed, I cannot but 
think that a desire to accomplish the indications recognized and urged 
by Dupuytren has led to the neglect of the indication which ought to 
have been regarded as of equal, if not of the greatest, importance, 
namely, the prevention of contractions and adhesions around and be- 
tween the joint surfaces. 

I cannot too often call the attention of the surgeon to the danger of 
tight bandages, to which I have frequently made reference elsewhere; 
and especially does it seem necessary here because I have recommended 
the use of the plaster of Paris bandage in this form of fracture, from 
which the greatest dangers are always to bo ;ippreliended, unless it is 
used carefully and skilfully. 

A- a genera] rule, the dressings ought to be wholly laid aside by the 
end of the third or fourth week; and although it maybe well for ;i some- 
what longer time to keep the foot turned in, by having it properly sup- 
ported as it lies upon tin- pillow, yet after tliis date I regard the use of 
splints and bandages ;i- only pernicious. 



580 FRACTURES OF THE TIBIA AND FIBULA. 



CHAPTER XXXIII. 

FKACTURES.OF THE TIBIA AND FIBULA. 

Causes. — A majority of these fractures are the results of direct blows 
or of crushing accidents, such as the kick of a horse, the passage of a 
loaded vehicle across the limb, the fall of heavy stones or timber, etc. 

In an analysis of two hundred and seventeen cases, where I could 
ascertain the cause, I have found the bones broken in the upper third 
from a direct cause seven times, and from an indirect cause three times. 
'In the middle third fifty-two have been referred to a direct cause, and 
ten to an indirect ; and in the lower third fifty to a direct cause, and 
thirty-two to an indirect. An observation which does not sustain the 
remark of Malgaigne, based upon his analysis of sixty-seven cases, that 
fractures of the upper third are produced by direct causes alone, those of 
the middle third much more frequently by indirect causes, and that those 
of the lower third are especially due to indirect causes. 

Of the indirect causes, falls upon the feet from a considerable height — 
as from a scaffolding, or from a top of a building — are by far the most 
common. Eight times I have found the bones broken by muscular action 
alone, as in the following example : 

Mrs. W., of Buffalo, aged about twenty-five years, and weighing at 
this time nearly two hundred pounds, was descending her door-steps with 
an infant in her arms, when, the steps being covered with ice, she slipped 
and fell, breaking her right leg just above the ankle. Mrs. W. says she 
felt and heard the bones snap before she touched the steps. Of this she 
is certain. 

I found the tibia broken obliquely, the fragments being quite mova- 
ble, but not much, if at all, displaced. The limb was dressed with a care- 
fully moulded and well-padded gutta-percha splint, and then laid in a 
pillow upon the bed. Mrs. W. experienced unusual pain from the frac- 
ture for several days, for the relief of which we were compelled at times 
to permit her to inhale chloroform. She was of a nervous temperament, 
and had frequently resorted to chloroform before to relieve neuralgic 
pains. The limb became very much swollen, and remained so for a 
week or two. No extension w T as ever employed. 

Within the usual time the bones united in perfect apposition, and in 
about four months she was able to walk without any halt. 

Pathological Anatomy. — We have seen that fractures of both bones 
through some part of the lower third are most frequent. Thus, of two 
hundred and seventeen fractures, twenty-two belonged to the upper third, 
seven to the middle, and one hundred and twenty-five to the lower. In 
some cases the two bones were broken in different divisions. It is often 
difficult, and sometimes quite impossible, to determine precisely where 
the fibula is broken ; but the analysis'is sufficently correct to illustrate 



FRACTURES OF THE TIBIA AXD FIBULA. 



581 



the much greater frequency of fractures of the lower third, and also the 
fact that the two hones generally break nearly on the same level ; usually 
the point of fracture in the tibia is between two and three inches above 
the joint. 

In an examination of twenty museum specimens, I have found both 
bones broken at the same point, or within two or three inches of the same 
point, sixteen times, and at extreme points four times ; and in these last 
examples the tibia has always been broken in the lower third, while the 
fibula has been broken in the upper third. 

In twenty of the fractures mentioned as belonging to the lower third 
only the malleolus of the tibia was broken, while the fibula was broken 
two or three inches above its lower end. Some of these were compli- 
cated with dislocation of the angle. 

I have seldom seen a transverse fracture of the tibia, except in its 
lower or upper extremity, in the expanded portions of the bone ; and 
even in those examples which w T e are accustomed to call transverse, 
because they are sufficiently so to prevent any sliding or overlapping of 
the fragments, there has existed, generally, a marked inclination of the 
line of fracture in one direction or another. 

The examples of fracture produced by muscular action have, without 
an exception, occurred in adults. Five of them were in the lower third 
of the leg, and three in the middle third. I think they were all of them 
nearly transverse, since they never became much, if at all, displaced. 

Most of the fractures of the tibia produced by falls upon the feet are 
very oblique, and the direction of the fracture is generally downwards, 
forwards, and inwards ; but I have found almost every conceivable 
variation from this general rule. 

The fracture in the fibula is even more constantly oblique than the 
fracture in the tibia ; but this is a point of very little practical conse- 
quence, and one which we can seldom determine positively, unless one of 
the fractured ends protrudes through the flesh. 

Fig. 232. 




Compound and comminuted fracture of the leg. 



Compound and comminuted fractures are more frequenl here than in 
any other of the bones of the body. My tables, which have rejected nil 
fractures demanding immediate amputation, most of which are compound, 



582 FRACTURES OF THE TIBIA AND FIBULA. 

do not for this reason give a just idea of their proportion to simple frac- 
tures, yel v\cn in these tables, of two hundred and seventeen fractures, 
seventy-four were compound, and also, frequently, more or less commi- 
nuted. Of eighty cases reported by W. W. Morland, of Boston, from 
the Massachusetts General Hospital, and in which the character of the 
accident is recorded, thirty -nine were compound. 1 

Symptoms. — The symptoms indicating a fracture of both bones of the 
leg are the same which are usually present in other fractures, namely, 
mobility, crepitus, shortening of the limb, distortion, swelling, etc. Gen- 
erally, the lower end of the upper fragment projects in front, and can be 
seen or felt ; but in some instances the swelling follows so rapidly that it 
is impossible to feel distinctly the point of fracture, and its existence can 
only be determined by the crepitus, mobility, and shortening of the limb, 
or, perhaps, by the marked deformity or deviation from the natural axis. 

The shortening, where it exists at all, varies at the first from a line or 
two to one inch. Generally, it is about half an inch. 

Dr. E. D. Merriam, of Conneaut, has reported to me a fracture of 
both bones of the leg, which occurred in his own person ; the tibia being 
broken transversely near its upper end, and that portion of the fibula 
being also broken off to which the biceps is attached. The small frag- 
ment of the fibula became tilted outwards, and in this position it has 
remained permanently. I have spoken of this form of fracture more 
fully in connection with fractures of the upper end of the fibula. 

Prognosis. — The average period of perfect union in twenty-nine cases, 
including those in which union was delayed by extraordinary causes 
beyond the usual time, was forty days. The general average, under 
ordinary circumstances, may be stated at about thirty days. 

Union has been noted as delayed a few weeks beyond the usual time 
in at least twelve cases of simple fracture. Cases of complete non-union 
are less frequent here than in the femur or humerus, the union taking 
place spontaneously often after the lapse of several months. I shall refer 
to this subject again when speaking of the treatment. 

F. C. T., of Erie Co., N. Y., aet. 35, had an oblique, simple fracture 
of both bones, in the upper third, caused by jumping from a buggy, in 
June, 1852. The limb was dressed with lateral splints, compresses, 
and bandages, and laid upon a pillow. Eight weeks after the fracture 
had occurred, the gentlemen in attendance wished me to see the limb 
with them. I found Mr. T. still in bed, and the fragments not at all 
united. 

Mr. T. had enjoyed average health heretofore, but he was never very 
robust. When I was called to see him he looked pale ; his skin was 
cold and moist, pulse 120, and appetite poor. The broken leg and foot 
were greatly swollen. The swelling was cedematous. Considerable 
excoriations existed on the back of the leg. The fragments were quite 
movable, and were overlapped three-quarters of an inch. 

We agreed that the patient ought, as soon as possible, to be got out 
of bed, so as to enable him to recover his strength, which had sadly de- 
clined. To this end, a gutta-percha splint was made to fit accurately 

1 Trans, of Mass. Med. Soc. for 1840; Fractures, by A. L. Pierson. 



FRACTUKES OF THE TIBIA AND FIBULA. 583 

the whole length of the leg : and. having attached a large number of 
tapes, it was secured upon the limb. Several times each day it was to 
be removed, and the limb bathed with brandy and water. Gradually, 
also, the limb was to be brought down to the floor, and the patient be 
made to sit up. and. as soon as possible, he was to walk with crutches, or 
to ride. 

Nov. 4. 1852. Mr. T. visited me at my house. The directions had 
been followed implicitly. About two weeks after nry visit he rode out, 
and in about nine weeks, or seventeen weeks from the time of the frac- 
ture, the bones were found united. His health and strength were quite 
restored, and the limb was no longer ocdematous. It was found to be 
straight, or with only a slight projection of the upper fragment in front 
:_.f the lower, and shortened three-quarters of an inch. 

In most oblique fractures of the shafts of these bones, union takes 
place with some shortening, the average being, even in simple fractures, 
about half an inch, but in some cases I have found the shortening one 
or even two inches. With judicious management, however, in simple 
fractures, this amount of shortening seldom or never occurs. 

Inasmuch, however, as among the claims lately instituted for the plas- 
ter of Paris dressing, it has been affirmed by at least one surgeon that 
it is competent to prevent in all cases shortening after fractures of the 
bones of the leg, as w r ell as of the thigh (see chapter on General Prog- 
nosis), it may be necessary to refer the question at once to the test of 
experience, and thus dispose of it before considering the subject of 
treatment. 

Flori Albert, aet. 24, fell, April 11, 1876, breaking his left leg three 
inches above the ankle, and was admitted to my service at Bellevue on 
the same day. My house surgeon, Dr. Thomas, while the limb was 
extended to its utmost, applied the plaster of Paris dressings from the 
toes to the knee. The dressings were removed, in my presence, at the 
end of six weeks, when the bones were found united with a shortening 
of "lie inch. 

Timothy Mahoney, set. 30. fell and broke his left leg by a twist of 
his foot. February 21, 187o. Admitted to Bellevue, ward 16. Fracture 
simple, oblique, and in lower third. Plaster of Paris was applied at once, 
while extension was made to the utmost. The splint was renewed once 
during the treatment, and on the 19th of April, the splint being removed, 
I found the limb united, and shortened three-quarters of an inch. 

These two cases will serve to illustrate what has been my experience 
at Bellevue and elsewhere with the plaster of Paris as ;i mean- of exten- 
sion. Of fifteen cases of* oblique fractures of the shafl in my record. 
the average shortening i- nearly three-quarters of* an inch, and all are 
shortened. It is not the practice generally at Bellevue to give an anaes- 
thetic in applying plaster to the leg, nor is it mentioned as having been 
used in more than one of the cases contained in Dr. Van Wagenen's 
table-, referred to in the chapter on General Prognosis. But, to deter- 
mine the value of" this method in a case of simple oblique fracture of 
both bones, I first measured the limb carefully before it was dressed, and 
found it shortened half an inch. The patient was then placed under 
the influence of an anaesthetic, and forcible extension made with pullers 



584 FRACTURES OF THE TIBIA AND FIBULA. 

until the limb was of the same length as the other. In this position it 
was retained until the plaster was applied, from the toes to above the 
knee, and had hardened. At the end of about six weeks the dressings 
were removed, and the limb was found to be shortened half an inch 
precisely the same as before the extension was employed. 

It is certain that this form of dressing makes no permanent extension 
within a range of three-quarters of an inch, and that, therefore, for all 
practical purposes, as a means of preventing shortening, it is useless. 

Generally, when a shortening has occurred, I have found the upper 
fragment in front of the lower, and oftener a little more upon the inner 
than upon the outer side. 

A deviation from the natural axis of the limb has been noticed by me 
in a good many instances. Several times the lower part of the limb has 
fallen backwards ; or, in consequence of its having rested too much upon 
the heel, it has inclined forwards ; and in other cases it has inclined 
inwards or outwards. 

Ulcers upon the back of the heel, seen by me many times, as a result 
of undue pressure upon this part, have, however, been presented but 
seldom in cases of simple fractures. 

It is not very unusual to find, also, over the exact point of fracture, 
and after the lapse of several months, or even years, an ulcer, or sinus, 
which is due sometimes to the presence of a small fragment of bone 
which has remained in the wound from the time of the accident, or to a 
thin scale which has subsequently exfoliated. In other cases it is due 
to the prominence of the salient angle when the lower part of the limb 
inclines considerably backwards ; and in still other cases, no doubt, to 
the general dyscrasy of the system, and to the same causes which pro- 
duce chronic ulcers in the lower extremities w T here only the skin has 
been originally injured. I have reported elsewhere examples of this 
complication existing after five months, two and three years, 1 and in the 
remarkable case which I shall now briefly relate an ulcer existed at the 
end of twenty-three years. 

Thurstone Carpenter, wdien four years old, received an injury, break- 
ing both bones of one of his legs near its middle. The fracture was 
compound. It was dressed and treated by an excellent surgeon, then 
residing in Buffalo, but long since dead. 

Twenty-three years after the accident, Mr. Carpenter called upon me 
on account of a paralysis of his lower extremities, which had recently 
occurred. He stated that from the time of the fracture until within 
about one year an open ulcer had existed over the seat of fracture, and 
that soon after it had closed over completely he began to lose the use of 
]ii> limbs. During the time it was open, small scales of bone have fre- 
quently been thrown off. The limb is half an inch shorter than the 
other, but straight. 

A gentleman residing in Quincy, Chautauqua, Co., N. Y., had his 
tibia and fibula broken near the ankle-joint in the year 1844, by the 
passage of a carriage-wheel across his limb. The skin was a good deal 
lacerated. The wounds, however, healed kindly, and the broken bones 

1 Trans. Amer. Med. Assoc. Report on Deformities after Fracture. 



FRACTURES OF THE TIBIA AND FIBULA. 585 

united in the usual time without any apparent deformity: but the limb 
continued swollen and painful, until finally suppuration took place. After 
twelve years of great suffering, I amputated the leg near its middle, from 
which time he made a speedy recovery. I found the lower end of the 
tibia inflamed, softened, and expanded, and containing in its interior 
about three ounces of pus, but no sequestrum. 

Anchylosis of the knee- or ankle-joint may follow as a result of the 
accident or of -improper treatment; and at one or both of these joints I 
have found more or less anchylosis at the end of nine months, one year, 
six years, twenty-five, thirty, and forty years. Generally, however, it 
disappears in a few weeks, and seldom remains to any considerable ex- 
tent in the knee-joint after the dressings have been removed two or three 
weeks ; but an Irishman called upon me in 1853, whose leg had been 
broken about three inches below the knee-joint six years before. It was 
a simple fracture. A surgeon in Ireland had treated the case. I found 
the limb shortened one inch and a half, the fragments being overlapped 
and displaced backwards at the point of fracture. The knee was also 
partly anchylosed. I could not learn what the treatment had been. 

In other cases, where no permanent anchylosis has followed, the 
ankle-joint has been occasionally painful, and subject to swellings, after 
the lapse of many years. 

In Muhlenberg's tables, already referred to in previous chapters, there 
are recorded 94 cases of delayed union or of non-union of these two 
bones at the same time ; also 84 similar cases where the tibia alone was 
ununited, and 2 in which the fibula alone was ununited: making a total 
of 180 cases. 

After all that has been said as to the occasionally serious nature of 
the consequences of these accidents, as shown in the shortening of the 
limbs, in their deviations from their natural axes, in the stiff* ankles, 
ulcers, and abscesses, it must be still admitted that in another point of 
view these results are not extraordinary, and may hereafter continue to 
be fairly anticipated in a certain proportion of cases, even under the best 
management ; since it must be understood that more fractures of the leg 
are attended with serious complications than of any other limb; and that 
while many produce death rapidly from the severity of the shock, and 
very many arc condemned at once to amputation, a large number of 
those which are saved have been in that condition which has rendered 
the application of bandages or splints impossible for many days. Indeed, 
few of these crooked limbs may still be presented as real triumphs 
of the art of surgery, Inasmuch as by consummate skill alone have they 
been saved. 

Treatment. — \x is wholly impossible in a class of fractures which 
presenl so greal a variety in regard to form, seat, and complications, to 
lish any universal system of practice: oevertheless it is possible to 
declare certain general principle- in reference to a few well-recognized 
classes or varieties : and [shall deem it especially importanl to record 
my disapproval of certain plan- of treatment which have from time to 
time been suggested and adopted. 

It is seldom that I have found it necessary or useful to apply any 
bandages directly to the skin, whatever form of apparatus has been em- 



586 FRACTURES OF THE TIBIA AND FIBULA. 

ployed ; but in certain cases of compound fractures, where primary dress- 
ings have been applied which needed support and protection, a bandage 
has been of service. The roller, unless the patient is a child, whose limb 
can be easily lifted and managed, is always objectionable ; but the many- 
tailed bandage, made of narrow strips of cloth, laid upon each other, as 
we have already described in our general remarks upon bandages, etc., 
is occasionally useful. 

Having made these preliminary dressings, we flex the leg to a right 
angle with the thigh, and by the hands make extension and counter- 
extension as much as the patient will bear, or as much as may be neces- 
sary to restore the fragments to place, in case this restoration is found 
to be practicable. If the fracture is compound, and the point of bone 
protrudes through the skin, it is often difficult to replace it. That is, 
we are unable to overcome the action of the muscles sufficiently to make 
the limb of its natural length, and for this reason, mainly, we are unable 
to get the point of bone beneath the skin. If we cannot then "set" the 
bone, or bring the ends into apposition, and this will be the fact pretty 
often, we still have no apology generally for leaving the bone outside of 
the skin. First, an attempt must be made to accomplish this reduction 
by pulling aside the skin with the fingers, or with a blunt hook. This 
simple procedure has often succeeded with me in a moment, when others 
have been trying in vain to accomplish the same end by pulling upon 
the limb. If this fails, then the skin should be cut sufficiently to allow 
the bone to retire, or if the point is sharp, and especially if it is stripped 
of its periosteum, it may be sawn or cut off. Resecting thus the end of 
an oblique fragment does not generally affect in any degree the length 
of the limb, or interfere with a prompt and perfect cure, but, on the 
contrary, it often is advantageous in every point of view. In certain 
exceptional cases we may find it advantageous to employ an anaesthetic 
to aid us in the reduction. 

We are now prepared to apply the splints. Before, however, consid- 
ering the character and form of the splints to be applied, it seems proper 
to call attention again to the danger of ligation of the limb from the 
tightness of the bandages, and especially from the use of a bandage or 
roller placed beneath the splints and directly against the skin. 

The large size and irregular form of the bones of the leg, the small 
amount of muscular tissue covering them, especially near the articula- 
tions, the severity of the injuries to which they are liable, with their 
remoteness from the centre of circulation — these circumstances alto- 
gether, render them exceedingly exposed to injury from the too great or 
unequal pressure of splints or of bandages ; and it has often occurred to 
myself, as it has to Dr. Norris, whose remarks upon this point I have 
already quoted, to find the skin vesicated, or even ulcerated and slough- 
ing, when the patients are first admitted to the hospital; a condition 
which, in nine cases out of ten, is due to the maladjustment of the 
splints, or to the tightness of the bandages. 

If bandages are used under the splints, and next to the skin, they 
must be applied very moderately tight, and loosened or cut as the swell- 
ing augments; and, from the first day of treatment to the last, the sur- 
geon must be careful to loosen or tighten the dressings when the swelling 



FRACTURES OF THE TIBIA AND FIBULA. 587 

increases or subsides, just as the prudent boatman trims his sails to the 
rising and foiling breeze. 

Dr. Krackowizer presented to the New York Pathological Society. 
June 10, 1863, a leg which he had amputated for gangrene occasioned 
bv tight bandages. A boy. five years old, sustained an injury of the 
ankle-joint, which his medical attendant pronounced a fracture of the 
fibula, and for which he applied only a tight bandage. The child suffered 
a good deal after the bandage was applied, and the following morning 
the toes were blue, but the doctor paid no attention to this circumstance. 
The pain subsided on the third day, and on the fourth the bandages 
were removed, and the limb found to be gangrenous. 

The specimen showed that the fibula was not broken, but that there 
was a fissure or crack in the lower part of the shaft of the tibia. 1 

The following case, which has been communicated to me by Dr. Ful- 
ler, of "Wyoming. X. Y.. with permission to make such use of it as I 
saw fit. is sufficiently pertinent and deserves a public record : 

A man. ret. 71, fell frorn a tree, striking upon his foot, August 27, 
1855, producing a backward dislocation of both the tibia and fibula upon 
the astragalus, and also a fracture of both bones of the^eg a few inches 
above the ankle. 

An empiric took charge of this unfortunate man. and immediately 
applied lateral splints and a firm roller from the toes to the knee. Not- 
withstanding the remonstrances and prayers of the patient to have the 
bandage loosened, it was kept on until the ninth day, when the doctor cut 
the bandage upon the top of the foot, and it was found vesicated. Igno- 
rant, however, as to the cause of this vesication, and of the danger which 
it threatened, he omitted to loosen the remainder of the bandages, and 
the limb was left in this condition until the twenty-third day. when Dr. 
Fuller being called, and having removed all the dressings, found the in- 
teguments covering the whole foot dead and dried down to the bones. 
The dislocation had not been reduced. Soon after this the limb became 
• edematous, and on the 27th of October the leg was amputated by Dr. 
Barrett, of Le Roy. from which time the patient recovered rapidly. 

The fragments being adjusted, two lateral splints of leather, long 
enough to extend from near the knee-joint to the metatarso-phalangeal 
articulations, and wide enough nearly to encircle the limb, are moulded 
to the limb on each side, and secured in place by successive turns of the 
roller. When the skin is delicate or tender, these should be underlaid 
with a thin sheet of cotton wadding or of sheet lint. A soft woollen 
cloth may answer the purpose equally well. A rack is then placed over 
the limb, such as will bo Been figured for the suspension of the limb when 
dressed with plaster of Paris, and from this the leg is suspended. The 
objects to be attained by tie- suspension are threefold: first, to avoid the 
danger of pressure upon the heel, and consequent ulceration ; second, to 
• nt that driving down of* the upper fragment upon the lower which 
constantly ensues when the foot rests upon the bed. or in a box which is 
immovable: third, to obviate movement of the fragments upon each 
other when the patient Bits up or lies down in bed. This movement, I 

Krackowizer, Amer. Med. Tin. 



538 FRACTURES OF THE T 1 15 1 A AND FIBULA. 

observe, is peculiar. It is not simply a motion of the fragments upon 
each other, as upon a pivot. at the point of fracture, which motion seldom 
interferes materially with consolidation, but it is a rising and falling of 
the upper fragment, or a motion to and fro of the fragments, and also 
a riding motion; either of which latter movements necessarily delays or 
defeats bony union. It is because these motions are generally permitted 
to occur in the usual modes of dressing these fractures, more than for 
any other reasons, that union is so often delayed in the case of these 
bones. In my own practice, when this plan of suspension is enforced, 
delay seldom occurs, but nothing is more common than for me to meet 
with it when other surgeons have had charge of the limb, and the sus- 
pension has been omitted. 

In suspending the limb, it is only necessary that the leg should float 
clear of the bed ; and I think it worth while to say that when lateral 
splints only are used, broad oval pieces of leather or of some other firm 
material should receive the limb in suspension, rather than narrow pieces 
of bandage, which soon become cords, and press unequally. To the 
sides of these oval pieces bands are attached, and their ends tied over 
the top of the rack. One must be placed under the knee and one under 
the ankle. 

If the fracture is above the middle of the leg, complete quietude of the 
fragments can only be obtained by carrying the splints and the bandages 
above the knee. 

I have already, in my remarks on the treatment of fractures in gen- 
eral, declared my acceptance of the so-called "immovable apparatus" 
in the treatment of certain fractures of the leg below the knee, and es- 
pecially of the plaster of Paris dressings. In hospital practice, where 
these dressings can be applied by experts, and where the limb can be 
watched daily and hourly, most or all of the dangers incident to this 
form of dressing may be avoided ; but even here I have occasionally seen, 
from a little too much delay in opening the dressings, serious trouble 
ensue. Its most devoted advocates, Seutin, Velpeau, and others, have 
never denied the necessity of caution in its use. To-day I hear of a 
surgeon in a neighboring State who has been prosecuted for damages in 
consequence of the death of the limb, caused, as is alleged, by this form 
of dressing. On the other hand, when applied judiciously, even imme- 
diately after the receipt of the injury, and when carefully watched and 
opened freely on the first notice of danger, it has, in my wards, and in 
the hands of my excellent house surgeons, often served its purpose more 
completely than any other apparatus or splints I have ever seen em- 
ployed. It has steadied and supported all parts of the limb more com- 
pletely, and permitted it to be handled more freely, than anything else 
could do. In simple fractures patients have been permitted to walk 
about upon crutches after the third or fourth day, and generally no harm 
has resulted. In one case, however, I believe this liberty caused a seri- 
ous delay in the union : and in another an abscess resulted, which would 
have been avoided if lie had remained in bed. 

But it is in the management of compound fractures of the leg that I 
have of late seen the greatest advantage in this mode of dressing; and 
it was in precisely these cases that 1 formerly believed the immovable 



FRACTURES OF THE TIBIA AND FIBULA. 589 

apparatus most objectionable. I do not wish, however, to retract anything 
I have heretofore said as to its dangers in most cases of recent fractures 
of the leg. or as to its ability to make permanent extension in all cases, 
whether the fracture is simple or compound. 

The following careful description of the proper mode of applying 
plaster of Paris bandages in fractures of the leg, has been prepared at my 
request by Dr. S. B. St. John, late House Surgeon to Bellevue Hospital. 
His large experience and his habits of accurate observation render his 
statements peculiarly trustworthy. 

••The materials necessary are, blanket, or cotton-wadding, blanket 
being preferable, and plaster of Paris bandages, which are prepared by 
rubbing dry plaster into the meshes of a bandage of coarse texture, and 
rolling it up so as to make it convenient of application. (These may be 
kept ready for use in tin cans.) The bones having been placed «$n posi- 
tion, the leg is placed upon the blanket, which is cut and folded neatly 
around it. and secured by a few pins. The blanket should extend from 
the base of the toes to the knee, or in case of fracture above the middle, 
or of compound fracture at any point, a few inches above the knee. The 
plaster bandages should then be immersed in hot water, to which a little 
salt has been added to hasten the setting, and while in the water they may 
be gently kneaded to insure moistening of every part. In about three 
minutes, or when bubbles of air cease to rise from them, they will be 
ready for use, and should be taken out as they are wanted, and gently 
squeezed to get rid of superfluous water. They are then to be applied 
after the fashion of an ordinary bandage, over the blanket, with just 
sufficient firmness to insure a complete fit. If, at any revolution of the 
bandage, the plaster is seen to be dry, it should be moistened by dipping 
the hand in water and rubbing it over the dry surface. Extra turns of 
the bandage should be taken at the places where it is necessary to secure 
extra strength to the splint. Three or four bandages (six yards long) 
are usually sufficient to make a firm splint. This splint will usually be 
sufficiently pliable just after its application to allow of rectification of any 
faulty position which may have occurred during its application. It should 
then be kept in shape by the pressure of the hands until it hardens, which 
will be in from ten to thirty minutes, according to the freshness of the 
plaster and texture of the bandages used. If, for any reason, it is de- 
sirable to cut the splint so as to admit of its removal, or to cut a fenestra 
through which to observe any part, this may best be done before the 
plaster becomes perfectly dry. say in from two to five hours after its ap- 
plication, depending upon the quality and freshness of the plaster. It 
will then cut like hard cheese, and a stout sharp knife should be used. 
In splitting a splint anteriorly, it is convenient at the same time to take 
out a piece about an inch wide, by making two parallel cuts one inch 
apart, one on either side of the median line, extending nearly through 
to the blanket, and then by raising the Strip at the upper edge, and cut- 
ting on either side alternately, the section may be completed, and the 
central slip removed without danger of cutting through the blanket and 
wounding the patient. The blanket may then be cut with scissors and 
the splint sprung off to examine the limb, if necessary. When replaced. 
a bandage should be applied over it. If it should be necessary to cul 



590 



FRACTURES OF THE TIBIA AND FIBULA. 



a splint which lias already become dry, and cuts with great difficulty, it 
may be softened with hot water, applied by a sponge in the track of the 
proposed section for ten or fifteen minutes. 

k ' If it is necessary to cut such a large fenestra that only a small strip 
of the splint would be left connecting its upper and lower portions, it 
is better to adopt a different plan of application. For this it is neces- 
sary to have a solution of plaster of Paris in water of the consistency of 
cream. A piece of blanket is then cut long enough to reach from the 
toes to the top of the proposed splint, and about fifteen inches wide. 
This is to be thoroughly soaked in the solution, and folded several times 
so as to be about two or three inches wide when folded. This is to be 
applied along that part of the limb which it is not necessary to keep 
under observation (if convenient, along its posterior aspect), and it is 
then to be secured in position by circular turns of the plaster bandage 
above and below the portion to be left exposed. Whenever a plaster 
apparatus extends above the knee, and it is proposed to sling the leg 
from a cradle, the leg should be flexed slightly upon the thigh, so that 
it may be swung horizontally. Any portion of a plaster splint exposed 
to the moisture of discharges or of water used in dressing should be 
carefully protected by oil silk and cotton-wadding. 

"In cases where not much swelling is anticipated, blanket is prefer- 
able to cotton-wadding, as an elastic medium between the splint and 
skin, because it is of more even thickness and retains its place better 
when the splint is removed, but cotton answers better when much swell- 
ing is anticipated, as being more elastic." 

The accompanying illustration (Fig. 233) has also been made for me by 

Fig. 233. 




Plaster of Paris dressing, and suspension. 

Dr. St. John, and furnishes a faithful picture of one of the many similar 
cases which have been under treatment by this method at Bellevue 
Hospital. 

Dr. George A. Van Wagenen, while acting as house surgeon at 
Bellevue, devised a most ingenious, simple, and effective apparatus for 
suspending the limb, which will be found illustrated in the accompanying 
woodcut (Fig. 234). 

" It consists of an elbow "| of wood projecting over the foot of the 
bed, from which the leg is suspended by two pieces of rubber tubing ; 
one above the ankle, the other just below the knee. The tubes have 



FRACTURES OF THE TIBIA AND FIBULA. 



591 



common grooved iron pulleys or wheels at each end ; those above, rolling 
on a large iron wire to allow motion toward the head or foot of the bed ; 
those below, at right angles to the others, holding the rings of rope in 
which the leg rotates ; this last being far the most important, allowing 
the patient to turn on either side. Motion on these rollers is accomplished 
with so little resistance that there is no pain. 



Fig. 234. 




Van Wagenen 



pension apparatus.- 



" The upright of the elbow to go at the foot of the bed should be long 
enough to rest on the floor, or any convenient part of the bedstead, and 
project about two feet above the level of the mattress, — the horizontal 
piece long enough to reach nearly to the knee; pine } by 2 inches is 
heavy enough. The angle made by these pieces is braced, and a strap 
of hoop-iron outside makes it very strong. In the horizontal piece two 
slots are cut wide enough to allow the iron pulleys to pass through, and 
of sufficient length to allow the patient to draw himself up and down in 
bed. A J- inch iron wire passes the whole length of this piece above the 
slots, steadied by small staples, so that it may be withdrawn. On this 
the upper pulleys run. The wire shields ! I above these slots are to 
prevent the bedclothes from resting upon the rollers. 

" The pulleys or wheels are fastened in the rubber tubes by making a 
few turns of copper wire around the iron screw of the pulley. This is 
pushed into the tube and bound outside with fine wire. 

" Rings of rope large enough to pass over the foot are then put 
through the lower pulleys. If these rings open, or the foot is slipped 
out of them, the leg is taken down without any of the apparatus about 
it. and the large wire may be withdrawn and the leg lowered, with the 
pulleys and rings still attached." 1 

There are a few cases in which a very much better position of the frag- 
ments can be secured by placing the patient under the influence of an 
anaesthetic, and by applying the dressings during complete anaesthesia. 
But the surgeon needs to be warned of two things in this connection : 
first, that just as much harm can be done to the soft parts by violent 

1 Van Wagenen, Med. Record, April 1. 1873. 



592 



FRACTURES OF THE TIBIA AND FIBULA. 



wrenching and pushing when the patient is insensible as when he is fully 
conscious; second, that while the patient is passing under the influence 
of an anaesthetic he is liable to violent muscular spasms, which may do 
serious injury. 

Dr. Banga, of Chicago, prefers stilts to suspension, as a means of 
support for his plaster splint. His method is a modification of a plan 
adopted by Ries, of Basle; but it does not seem to me to possess any 
advantages over suspension. 1 

What is known as the Bavarian method of using plaster of Paris has 
been adopted by some American surgeons, which consists essentially in 
leaving the splint open in front and behind, or in leaving it connected 
posteriorly only by a strip of cloth, which serves as a hinge. This plan 
has been especially recommended by Prof. James L. Little, of this city, 
by Prof. W. W. Dawson, of Cincinnati, and by Dr. G. Wackerhagen, 2 



Fig. 235 




G. Wackerhagen 



of Brooklyn, N. Y. By this method all danger of strangulation is 
avoided. As between this plan and the use of sole leather, which can 
be made to fit as accurately, or nearly so, as plaster of Paris, it is, 
therefore, a question of convenience rather than of practical utility. 

In such few cases as demand or warrant a resort to permanent exten- 
sion and counter-extension, a double-inclined plane furnishes a conve- 
nient mode for its accomplishment; but it is only occasionally that, in 
fractures of the leg, permanent extension and counter-extension can be 
employed ; an assertion which, however much it may surprise the inex- 
perienced, observation will prove to be true. If the fracture is near 
the middle of the leg, quite remote from the points upon which the ap- 

1 Banga. Chicago Med. Journ. and Examiner, June, 1877. 
- "Wackerhagen, Hosp. Gazette, May 24, 1879. 



FRACTURES OF THE TIBIA AND FIBULA. 



593 



pliances for extension, etc., are to be made fast, and the inflammation is 
moderate, something may be done in this way ; but when the point of 
fracture approaches the ankle-joint, as it actually does in a great majority 
of cases, a gaiter, made of any material whatever, if it has sufficient 
firmness to overcome completely the action of the muscles, will inevitably 
cause congestion and swelling, accompanied sooner or later with great 
pain and with ulcerations, and simply because the extension is made 
directly upon parts already tender and inflamed from the accident itself; 
and when we add to this complete and violent ligation of the limb near 
the seat of fracture, a similar ligation of the limb just below the knee, 
for the purpose of making counter-extension, as was done in what is known 
among American surgeons as "Hutchinson's splint," 1 we are prepared 

Fig. 236. 




James Hutchinson's splint, for extension, etc.. in fractures of the leg. (From Gibson.) 



to understand how the worst consequences may ensue. I have once 
seen, when this abominable apparatus had been used, a complete ring of 
ulceration below the knee, and another as complete around the foot and 
ankle. The limb was twice girdled, and yet the surgeon thought he was 
performing a duty for the omission of which he would scarcely have been 
regarded as excusable. 

Jar vis's adjuster, a still more mischievous, inasmuch as it is a more 
powerful instrument, operating in a similar manner, has been productive 
of like consequences; but Jarvis's adjuster is liable to the additional 
objection that by its great weight it drags off the limb, turning the toes 
outwards, an objection which no care or diligence can generally over- 
come. 

I could wish that neither of these appliances would ever again be im- 
pressed into the service of broken legs. 

Xeill, of Philadelphia, and others have sought to overcome some of 
the difficulties in the way of making extension in fractures of the legs, 
by substituting adhesive plaster for the usual extending or counter- 
extending bands. 

- I))-. Neill: "For simple fractures of both bones of the leg, 

1 Element- of Surgery, by John Syng Doisey, vol. i. p. 181. Philadelphia, 1813. 



59-4 



FRACTURES OF THE TIBIA AND FIBULA. 



attended with shortening and deformity not easily overcome, the limb 
should be placed in a long fracture-box with sides extending as high as 
the middle of the thigh, and a pillow should be used for compresses. 

" The counter-extension is made by strips of adhesive plaster, one 
inch and a half in breadth, secured on each side of the leg below the 



Fig. 237. 




John Neill's apparatus for fractures of the leg requiring extension and counter-extension. 

knee, and above the seat of fracture by narrower strips of plaster 
applied circularly. The end of the counter-extending strips may then 
be secured to holes in the upper end of the sides of the fracture-box, by 
which the line of the counter-extension is rendered nearly parallel with 
the limb. 

"The extension is also to be made by adhesive strips, in a mode 
which is now well known and understood. The ends of the extending 
bands may be fastened to the foot-board of the box." 1 

Dr. Neill further remarks: u In compound fractures of the leg, short- 
ening and deformity are often difficult to overcome, as is well known to 



Fig. 238. 




John Neill's apparatus for compound fractures of the leg. 

experienced surgeons. In such cases we may wish to dress the wounded 
soft parts, and, at the same time, maintain a certain amount of extension 
and counter-extension. 

" This can be readily accomplished by having the sides of the frac- 
ture-box sawed in two parts at the knee, so that the sides of the box 
above the knee, from the upper ends of which the counter-extension is 
made, need not be disturbed during the dressing, while that portion of 
tli<' side of the box corresponding to the leg may be opened at pleasure, 
without diminishing the tension of the extending or counter-extending 
band-. 

In compound fractures of the leg, Dr. Gilbert recommends a modifi- 
cation of the common fracture-box. In this apparatus the foot-board is 

1 Philadelphia Med. Exam., vol. xi. p. 580, 1855. 



FRACTURES OF THE TIBIA AND FIBULA. 



595 



omitted, and a block for the reception of the frame of the tourniquet is 
substituted. Each side of the box consists of three separate segments. 
Of these the upper and lower are permanently screwed to the bottom 
board, and the central one is attached by hinges. By this arrangement 
there is full access to the wound, which may be dressed from day to day 

Fig. 239 




Gilbert's box for compound fracture of the leg. 
1. The four counter-extending adhesive strips, as if encircling the knee and upper part of 
leg. 2. The two extending adhesive strips crossing at the bottom of the foot, ready to be 
applied to the foot. 3. Tourniquet. 

without disturbing the extension and counter-extension, maintained by 
the permanently attached upper and lower segments. 

The following woodcuts are intended to illustrate an apparatus invented 
by R. 0. Crandall, for the purpose of making permanent extension. The 



Fig. 240. 




Section of Crandall's apparatus, applied to the limb; showing adhe 
extending bands and gaiter for extension, etc. 



ive plaster counter- 



extension is represented as being made by a gaiter, but Dr. Crandall 
leaves it to the choice of the surgeon whether he shall employ the gaiter 
or adhesive strips. 1 

Without intending to deny to these contrivances for permanent exten- 
Bion much ingenuity and some little practical value, I am far from con- 
ceding that they will be found capable of overcoming the action of the 
muscles where the ends of the fragments do not support each other. 
Their mode of action is such that they can scarcely do more than to 
steady the limb, and if they operate upon the fragments at all in the 
direction of their axes, it must be only in the most inconsiderable degree. 
The adhesive plasters are substituted for the circular knee-bands and the 

1 Crandall, Phil. Med. Journ., vol. iv. p. 103, Jan. 1866; also Transac. of Med. 
Assoc, of Southern and Central New York, 1855, pp. 81, 82. 



596 



FRACTURES OF THE TIBIA AND FIBULA. 



gaiters, an ith a view to avoid ligation; but in order to do this they must 
not encircle the Limb, but only be laid parallel to its long axis. The leg 
of an adult, or that portion to which the adhesive plasters can be applied, 
supposing the fracture to be exactly at the centre, may be sixteen inches, 
that is, eight inches for extension and eight for counter-extension ; but 
when we employ the same means for extension in fractures of the thigh, 
we find it necessary to apply the strips over the whole of these sixteen 
inches, the entire length of the leg, or they will not hold. It will be 

Fig. 241. 




Crandall's apparatus complete. The counter-extending straps are passed over a block of 
wood, supported above the knee, to prevent their pressure upon the sides of the knee. 

apparent also that we cannot use even the eight inches which we have, 
for the purpose of argument, allowed these gentlemen in fractures of the 
leg. There must be at least a space of eight inches between the ends of 
the two opposing strips in order that they may operate at all upon the 
fragments ; indeed, I do not believe that even then their influence would 
reach beyond the skin to which they were directly applied ; but if a 
space of eight inches is left, only four remain for the strips at either 



Fig. 242. 




Posterior view of the lower portion of Crandall's apparatus. 

end ; and this is an amount of surface wholly insufficient for our purpose. 
What, then, shall we do when the fracture is near one of the extremities 
of the bone ? These gentlemen seem to have forgotten, moreover, that 
the whole leg is tender, and that the skin easily vesicates. In short, 
they have not seen the many points of difference between the application 
of these means in fractures of the thigh and leg, and which, while they 
allow us to accomplish all that Ave could desire with the one, are of little 
or no use in the other. We shall then always come to the same conclu- 
sion : whatever means Ave may employ to make permanent extension in 
fractures of the leg, we must either fail to accomplish all that we desire, 
or incur the hazards incident to complete and firm ligation of the limb ; 
and if the preference is given to any form of apparatus to accomplish 



FKACTURES OF THE TIBIA AXD FIBULA. 



597 



these ends, it must be to some form of the double-inclined plane, by which 
we may at least avoid ligation in the upper part of the limb, the counter- 
extension being made against the under surface of the thigh while it is 
resting upon the thigh-piece ; or to one of the long straight thigh-splints, 
which will enable us to make the counter-extension from the thigh and 
perineum. 

If a double-inclined plane is used, I prefer either a plain apparatus, such 
as Ave have already described as in use for fractures of the thigh, con- 

Fig. 243. 




Liston's double-inclined plane, applied to the leg in case of compound fracture. (From Miller.) 



structed of boards, joined together by hinges opposite the knee, and with 
an upright foot-board, upon which a carefully arranged and thick cushion 
has been placed; or the more elegant double-inclined plane of Liston. 

In using Liston's apparatus, it must not be inferred that the knee is 
always to be bent. The apparatus is designed to be used occasionally 

Fro. 244. 




Louis Bauer's wire splints for the leg. 1 



as a straight splint; and there will be found many cases of fractures of 
the legs in which the straight position will be most suitable: this is espe- 
cially true of such fractures as, occurring just below the knee-joint, have 
the line of fracture directed obliquely downwards and forwards. But 
there are many compound fractures which demand the same extended 

r JJauer. Buffalo Medical Journal, April, 18-37, vol. xii. 



598 



FRACTURES OF THE TIBIA AND FIBULA. 



position: and in nearly all rases where this form of apparatus is used as 
a double-inclined plane, the lower end of the splint should be elevated 
so that the heel shall not be much below the level of the knee. 



Fig. 245. 




Swing box or "cradle." (From Skey.) 

Bauer's wire splints, used also for side-splints, when they are formed 
to fit the limb accurately, possess some advantages which must recom- 
mend them to the attention of surgeons ; but neither these splints nor 
any other, however accurately fitted, ought to be applied directly to 
the naked skin. They require always the interposition of a well-padded 
lining. 





Fig. 246. 






!! 


'-\- ] ® 


__J 






\f 






V 


<i 






a 


If 




Salter's cradle. (From Fergusson.) 



Boxes are rarely useful except in certain compound fractures. They 
are heavy and awkward machines, which prevent the patient from moving 
readily in bed: or which, being fixed, if he does move, allow the upper 
fragment only to descend, or to move upon the lower as a fixed point. 



FRACTURES OF THE TIBIA AND FIBULA. 



599 



If used at all, they ought generally to be suspended, or made to move 
ou a suspended railway. But however they are arranged, the limb is a 
great part of the time concealed from sight, and the surgeon is prevented 
from making use of such means to rectify deviations in the line of the 
bone as he would probably have otherwise employed. 

The swing invented by James Salter, of London, is constructed so as 
to allow not only a lateral motion, but also a more complete motion in 
the direction of the axis of the limb, by which the danger of pushing the 
fragments upon each other is obviated. This is accomplished by the 
rolling of two pulley-wheels upon a horizontal bar. The case in which 
the leg rests may be made of metal or of wood, and the frame of iron, 
for the sake of lightness and strength. 

Dr. Hodgen, of St. Louis, suspends the box over a pulley placed 
transversely, so that by drawing the rope to the right or to the left, the 
box may be turned upon either side. 

The suspension apparatus devised by Dr. John W. Trader, of Sedalia, 
Missouri, for the treatment of compound fractures of the leg, when it is 
desired to employ irrigation. I have found very useful in my wards at 



Fig. 247. 



Fig. 248. 




John W. Trader's suspension apparatus for compound 
fractures. 



Fracture-box, with movable 
sides. 



Bellevue. The limb is suspended by transverse strips of cloth, over a 
tray, from which the water is conducted by nozzles. I have found it 
convenient to attach India-rubber tubing to these nozzles, through which 
the water may be conveyed to a pail placed beside the bed. We have 
used it satisfactorily, also, for other cases than fractures. 

Fracture-boxes, employed in the treatment of compound fractures of 
the leg, are. in this country, sometimes filled with bran : the bran being 
closely packed upon all sides so as to support the limb uniformly and 
gently. This method of treating compound fractures of the leg was first 
suggested by J. Rhea Barton, of Philadelphia, 1 and has been much used 
in the Pennsylvania Hospital: and more lately it 1ms been introduced 
into the Bellevue and New York City Bospitals. It possesses the ad- 
vantage of affording a perfect protectioD against flies in the summer 
ii. and of* absorbing the matter as it escapes. 

In using the '• bnm-bow" the sides are first brought up into position 
and made fast. A piece of muslin cloth, one yard in length by half a 

1 Barton, Amer. Journ. of Med. Bci M vol. xvi. p. 31, and vol. xix. p. 616. 



000 



FRACTURES OF THE TIBIA AND FIBULA. 



yard in breadth, is then laid upon the box, and into this the bran is 
ponied, until it is about one-fourth full. The bran is then distributed so 
as to lit the back of the leg, and the limb is placed in position. After 
which, additional bran is packed on either side of the limb, until it is 
nearly or quite enveloped ; the wounds being first covered by pieces of 
lint smeared with simple cerate. Finally, the upper portion of the muslin 
sack is fastened around the limb just above the knee, to prevent the 
escape of the bran. 

Whenever any portion of it becomes soiled by blood or pus, it may be 
dipped out with a spoon, and its place supplied with fresh bran. The 
support which it gives to the limb is also uniform without being at any 
time excessive : and Dr. Coates states that the escape of blood in rapid 
hemorrhages has been known to increase the bulk of the bran sufficiently 
to arrest the bleeding by its accumulated pressure. 

Dr. L. D. Mason, of Brooklyn, N. Y., has carbolized the bran, by 
stirring in a small quantity of carbolic acid. 1 

In whatever position the leg is placed, and with many of the forms of 
apparatus which I have enumerated, it will be found necessary to pro- 
tect the limb from the weight of the bedclothes 
by some contrivance similar to that figured in 
the accompanying drawing ; or by a rack, such 
as is represented for suspending the leg when 
leather splints or the immovable apparatus is 
employed. 

Malgaigne, who declares that every surgeon 
knows how impossible it is, in an immense ma- 
jority of cases, to overcome the projection of 
the superior fragment when the limb is placed in the extended position 
(over a double-inclined plane), and who affirms that neither Pott's posi- 
tion, nor Dupuytren's modification of it, will do much if any better, nor, 



Fig. 249. 




"Wire rack for fracture of leg. 



Fig. 250. 




Malgaigne'8 apparatus for oblique fractures of the leg. (From Malgaigne.) 

inded, that Laugier's plan of cutting the tendo Achillis possesses in this 
respect any real advantage, concludes at last to resort to a new and really 
ingenious method, the value of which, also, he claims to have already 
fully demonstrated. His apparatus consists simply of a steel band of 
sufficient size to encircle three-fourths of the limb, at the two extremities 
of which are two horizontal mortises through which a band is passed, and 



Mason, X. V. .Med. Journ., Sept. 1876, p. 253. 



FRACTURES OF THE TIBIA AXD FIBULA. 



601 



which may be buckled upon itself behind. The centre of the metallic 
arch, in front, is penetrated with a firm metallic screw, terminating in a 
very sharp point, and which is moved by a flat thumb-piece. 

The limb being laid over a doubled-inclined plane, and the pads being 
carefully adjusted, as we have already directed when speaking of other 
forms of apparatus, and the limb properly extended, the apparatus of 
Malgaigne is placed over the limb, with the sharp point of the screw 
resting upon the upper fragment, a few lines above the point of fracture : 
and at the same moment that this point is pressed firmly down to the 
bone, the fragments being held together by an assistant, the strap is 
buckled as tightly as possible under the splint. A few turns of the 

Fig. 251. 




Malgaigne's apparatus applied. (From Malgaigne.) 

screw will now make its point penetrate more deeply into the bone, and 
insure the most complete apposition of the broken extremities. " This 
is accomplished," says Malgaigne, "with very little pain to the patient;" 
and, as will be seen, the steel arch effectually prevents any ligation of the 
limb. I cannot say that the plan receives my unqualified approval ; yet 
I have employed it to advantage in some cases of old ununited fractures. 

Treatment of Delayed or Xon-umon. — It has already been remarked 
that pretty frequently in this fracture union is delayed considerably 
beyond the usual period of six or eight weeks, but that in a large major- 
ity of these cases of delayed union consolidation is finally accomplished 
without any surgical operation. This is most often effected by permit- 
ting the patient to rise and go about on crutches, the fragments being 
supported by some light but firm splint, which will permit also the limb 
to be opened daily and washed or rubbed gently, so as to restore its cir- 
culation. In some few cases, after the lapse of several months, if this 
method has not succeeded, the bones have been known to unite firmly in 
ar oi- two, without side-splints, and even when the patient lias been 
bearing hi- weight upon the limb. But such a result is rare, and is 
tpected. If*, indeed, the union is not effected within four 
or five months with the splints and crutches, it is better to resort a1 once 
to perforation between the fragments, as has been directed in the general 
chapter on Delayed or Non-union of the Bones. 

A few illustrative examples will serve, perhaps, to enforce these state- 
ments. 



602 FRAOTUBES OF THE TIBIA AND FIBULA. 

John Connor, aet. 28, was admitted to Bellevue Hospital, Oct. 31, 
W"'. 1 . with a simple fracture of his leg below its middle. The limb was 
placed in a fracture-box, but not suspended, where it remained six weeks. 
A starch bandage was then applied, and continued two months. About 
the middle of February the fragments were perforated, and the starch 
bandage again applied. March 3d, the patient having come under my 
care. I substituted leather splints for the starch, and directed him to go 
about on crutches. April 2d, finding that union had not taken place, I 
perforated the fragments thoroughly, applied the splints, and allowed 
him again to use his crutches. A few months later I was informed that 
bony union had taken place. 

Alary Welsh, aet. 28, was admitted to Bellevue with a simple fracture 
of the leg near the upper end of the lower third. Within one w r eek it 
was inclosed in a plaster of Paris dressing. At five weeks there was no 
union. The plaster splint was renewed, and she was allowed to go about 
on crutches. No bony union at ten weeks. Splints and bandages were 
then removed, and she continued to walk with crutches, and in one 
month the union was firm. 

Cornelius Hash rook. ret. 36. had his left leg broken by a direct blow 
June 16, 1877 — fracture comminuted. A surgeon placed the limb in a 
"bran box" until the swelling had subsided, and then applied a plaster 
of Paris dressing, whch was removed in four weeks. The fibula had 
united, but not the tibia. The splint w r as kept on, and he was allowed 
to go upon crutches. He consulted me eight months after the accident. 
I found the limb much wasted, and no bony union of the tibia. He was 
advised to lay aside his crutches and to remove the splints, and to walk 
about. This advice was followed by his surgeon, Dr. Herrich, of Pas- 
saic, except that he was permitted occasionally to use crutches. In about 
four months the union was firm, the limb being a little bent outwards at 
the seat of fracture, and shortened three-quarters of an inch. 

The following is the only case I can recall in which I have found these 
bones ununited at the end of a period so long as four years : 

A gentleman, aet. 33. from Bergen, N. Y., was struck by a billet of 
wood on the 3d of August. 1856, breaking his left leg just below the 
knee. The fracture of the tibia was transverse. His surgeon dressed 
the limb on a double-inclined plane. Four years later he consulted me, 
when I found the bones still ununited, although he was in perfect health, 
and had been constantly using the limb. I advised perforation, but he 
did not consent, and I have never heard from him since. 

In Dr. Muhlenberg's tables of delayed union and ununited fractures, 
in a total of 94 examples involving both bones. 71 were finally cured, 3 
were relieved, 19 failed, and 1 died. It might be more proper to say 71 
were cured, ami 23 failed. 

Of these, 1 ( » were cured by friction. :i<> by mechanical appliances and 
immobilization, 4 by seton, l >( » by resection, and 10 by drilling. 1 died 
after resection. 1 

Resection "//</ Refracture "J' ( booked Legs. — In some cases of extreme 
deformity of the legs consequent upon badly united fractures, resection 
of the bone- has been practised with more or less success. 

1 Muhlenberg, Agnew's Surg., vol. i. p. 866. 



FRACTURES OF THE TIBIA AND FIBULA. 603 

A case of resection is reported by Charles Parry, of Indianapolis, 
Ind. A young man, set. 15, having broken his leg near its middle, the 
fragments united, from some cause, nearly at right angles with each other. 
Some years afterwards, on the 15th day of January, 1838, Dr. Parry 
operated, by removing a wedge-shaped portion from both the tibia and 
fibula. The recovery was tedious, but satisfactory. 1 

Mr. Key, of London, made an operation of this kind upon a gentle- 
man who had suffered a fracture of the right tibia from a musket-ball. 
The limb was nearly useless, since he could only bring his toes to the 
ground. Mr. Key operated in October, 1838, and when the report of 
the case was made, five months subsequently, the patient was doing well. 2 

In September, 1840, Dr. Miitter, of Philadelphia, made a similar 
operation upon a patient, whose leg was shortened three inches and a 
half, and very much deformed; by which operation, when the recovery 
was complete, the shortening was considerably reduced. 3 

Gurlt 4 in a record of 25 resections for badly united fractures of these 
bones, reports 19 as cured, 2 deaths, 1 amputation, and 2 failures. 

More often cases are presented of badly united fractures of the leg, 
which seem to justify a resort to refracture ; and, while this procedure 
is attended with little or no danger to life, after neither resection nor 
refracture can we always make sure of a reunion. If, moreover, the 
surgeon expects, by a refracture, to lengthen a limb much, where it is 
merely overlapped and shortened, he is, I am certain, destined to disap- 
pointment, at least in all cases where sufficient time has elapsed for the 
bones to have become firmly united. I have myself several times re- 
fractured bones; and I have several times met with cases of old fractures 
newly broken ; and I have constantly observed that I could never, in the 
end, make them but very little if any longer than they were before the 
refracture. The muscles had contracted and shortened, and their con- 
traction could not be overcome. In the case reported by Miitter, he 
believed that he stretched the muscles two inches. With all deference 
for the skill and honesty of this gentleman, I think that he was mistaken. 

If. however, the object of the refracture is to straighten the limb, then 
no doubt it may be sometimes accomplished; and in some degree also 
by the straightening of the limb the shortening may be overcome ; but 
in my opinion, such procedures ought to be reserved for extraordinary 
circumstances, unless the refracture can be made soon after the union 
has taken place. In those cases in which I have refractured the tibia 
and fibula after a recent union, the bones have reunited promptly. 

An instructive case of refracture is reported by Dr. Horner, of Phila- 
delphia, in the Medical Examiner. The limb had been broken eight 
week-, and was quite crooked, but was not very firmly united, and Dr. 

1 Parry, Amer. Journ. Med. Sci., August, 1839, p. 334, 

- Key, Amer. Journ. Med. Sci., Aug. 1839, p. 339; from Guv's Hospital Reports, 
April. 1839. 

■ Mutter, Amer. Journ. Med. Sri.. April, 1842, p. 359. Three similar case- may 
also be found in the Oct. X" f'"r 1841, and theApril No. for 1842 of the same journal, 
in which the operation was made by Portal, of Palermo. Malgaigne mentions two 
other examples. 

4 Poinsot, op. cit., p. 692. 



604 FRACTURES OF THE TARSAL BONES. 

Horner, having refract urn I it, was able at once to restore it to a nearly 
straight line. 1 

Mary McCormick, set. 5, 342 £. Twenty-third Street, broke her left 
leg Dear the upper end of the lower third. A doctor was called who 
did not recognize the fracture. Probably it was a green-stick fracture, 
and do splints were applied. Six months later she was taken to another 
excellent surgeon in this city, who found it greatly bent at the seat of 
fracture, and he refractured it. The child remained a long time in bed 
with splints, and when I was consulted in 1868, about eighteen months 
after the refracture, no bony union had taken place. 

T. B. Johns, of Terre Haute, Indiana, had his right leg broken near 
its middle. Under the care of Prof. John E. Link, of the same place, 
it united. In Nov. 1876, ten years after the first accident, he w T as thrown 
from a horse, and it was refractured at the same point, after which the 
tibia refused to unite. Six months later he consulted me, and I advised 
perforation at the seat of fracture. I am imformed that Dr. Pancoast, 
of Philadelphia, subsequently brought about union by perforation, but 
that extensive suppuration ensued, and that the cure was not accom- 
plished in less than six months. 

In the case of Blair, related in connection with fractures of the tibia, 
and which was finally treated successfully by me by perforation, the 
fragments united after the original accident, and were refractured at the 
end of six weeks by an attempt to overcome an anchylosis at the knee- 
joint. They refused thereafter to unite until placed under my charge. 



CHAPTER XXXIV. 

FEACTTJEES OF THE TAESAL BONES. 

<'<tiises. — The astragalus is generally broken by a fall from a height, 
the patient having struck upon the bottom of the foot. Monahan, in an 
analysis often cases, found it had been broken by a fall upon the foot 
nine times, 2 and only once by a crushing accident. 

Dr. F. J. Shepherd, 3 of the McGill University, Montreal, has called 
attention to a fracture of the "little process of the astragalus external to 
the groove for the tendon of the flexor longus hallucis muscle," to which 
is attached the posterior fasciculus of the external lateral ligament of 
the ankle-joint. He has met with four examples in the dissecting-room. 
All of them without a history. The first was a man about 25 years old; 
righl toot: and it had united to the main portion by fibrous tissue. 
The second was also in a young man; right foot; with neither fibrous 

1 Eorner, New York Journ .Mod., May, 1851, p. 432. 

'-' Fracture of the astragalus, with analysis of the recorded cases of this injury. An 
inaugural thesis, presented t-> the faculty of the Buffalo Med. Col., March. 1858, by 
Bernard Monahan, M.D. 

Shepherd, Journ. Anat. and Physiology, vol. xvi. p. 79. 



FRACTURES OF THE TARSAL BONES. 605 

nor bony union. It remained attached to the posterior fasciculus of the 
external lateral ligament, but it was displaced slightly outwards, and was 
quite movable. In the third case the process had been broken off; 
right leg; and it had become reunited by bone The fourth case was 
found in a woman aged about 69, whose bones had undergone fatty 
degeneration. The fragment had united by fibrous tissue. 

Dr. Shepherd was unable to produce this lesion upon the cadaver; but 
he calls attention to the fact that this process is much more prominent in 
some persons than in others ; and furthermore, since in none of these 
cases was there a noticeable deformity of the foot, it would naturally be 
overlooked, or be regarded as a mere sprain. 

The calcaneum is also occasionally broken by violent lateral pressure, 
but much more often by a fall upon the foot, or rather upon the heel. 

Abel, of Stettin, 1 has called attention to a fracture of the little apophy- 
sis of the calcaneum (lesser process, or sustentaculum tali ; the tubercle 
situated above the groove for the tendon of the peroneus longus, and 
called by Henle, the "trochlear apophysis"), the apophysis being broken 
by a fall upon the foot when in the position of varus. Biddle 2 has 
seen the same lesion, caused in the same manner in a man 39 years 
old, and which he ascribed to the action of the peroneo-calcanean liga- 
ment (middle fasciculus of the external lateral ligament). After the lesion 
the foot becomes everted, and flattened as in valgus, and the length of 
the heel is apparently shortened by a slight displacement of the calcaneum 
forwards. 

In some instances both heel-bones have been broken at the same moment. 

Malgaigne has collected eight cases of fracture of this bone by mus- 
cular action, as in jumping upon the toes, the posterior portion of the 
bone being thus violently acted upon by the tendo Achillis. South, in 
his Xotes to Chelius, has mentioned two other cases, one of which was 
seen by Lawrence, and has been reported in the second volume of the 
Lancet. This person had received the injury by jumping off a stage- 
coach. The fragment was found to be drawn upwards slightly, but not 
so far as to prevent crepitus when the muscles on the back of the leg 
were relaxed. The other example mentioned by South is a cabinet 
specimen contained in the museum of St. Bartholomew's Hospital. The 
fracture had taken place just below the attachment of the tendo Achillis, 
but the upper fragment was not displaced. 3 Mr. Cooper mentions two 
other cases, both produced by violent efforts on the part of the patients 
to sustain themselves when falling. In one of these the fragment was 
immediately drawn up three inches. 4 Burggraeve, 5 Coote, 6 Anningson, 7 
and Poinsot 8 have met with the same accident from a similar cause. 

The other bones of the tarsus are generally broken by crushing acci- 

1 Abel, Arch, fur Klin. Chir., 1878, Bd. xxii. Hft 2. 

2 Bidder. Cent, fur Chir., 1881, p. 733 (Poinsot). 

\ tes to Chelius's Surgery, vol p. 639, Amcr. ed. 
* B. I ■. of Sir Astley, Amer. ed., p. 311. 

5 Buiggraeve, Bull. Acad. Roy. do M.'d. de Belgique, t. 6, j>. 886, 1863. 
e ' Coote, Thetanest, 1867, t. I, p. 270 (Poinsot). 
7 Anningson, Brit. Med. Journ., 1878, vol. i. p. 128. 
' Poinsot, op cit., p. 695. 



606 FBACTURBS OF THE TARSAL BONES. 

dents, such as the fall of heavy weights upon them, by the passage of 
loaded vehicles, etc. 

Pathology. — The astragalus often, indeed generally, escapes without 
injury in those crushing accidents which break many or most of the 
other bones of the foot, and, as Ave have seen, it is seldom broken except 
when the patient has fallen upon the bottom of his foot; but at the same 
moment, the foot being turned forcibly out or in, a dislocation of the 
tibia takes place, and the fibula is broken. In nine of the cases collected 
by Monahan, one or the other of these forms of dislocation had occurred, 
in eight of which the dislocation was compound. The direction of the 
fracture is found to vary greatly ; thus, it has been found broken in its 
length antero-posteriorly, in its breadth or transversely, and in one in- 
stance it has been divided nearly horizontally, so as to separate the upper 
face completely from the lower. Sometimes it suffers a species of im- 
paction, the fragments being actually driven into each other ; at other 
times, as in one case related by Amesbury, the bone may be split with- 
out the occurrence of any displacement. 

The calcaneum also may be broken in any direction, and it is equally 
with the astragalus liable to impaction, by which its vertical diameter 
is sensibly diminished, while its transverse diameter is increased. If 
the fracture is a consequence of muscular action, the line of fracture is 
always posterior to the astragalus, aud in some cases only that portion 
is broken off to which the tendo Achillis has its attachment. It may 
be broken also vertically, directly underneath the astragalus, in which 
case the lateral and interosseous ligaments will prevent anything more 
than a slight displacement of the posterior fragment. When the frac- 
ture takes place posterior to the lateral ligaments, the detached frag- 
ment is liable to be drawn very far from the body of the bone, even to 
the extent of four or five inches, and possibly farther when the leg is 
extended upon the thigh and the foot flexed upon the leg. Constance 
relates a case in which the tuberosity, having been broken off by a direct 
blow, was drawn up five inches. 1 

Fractures of the calcaneum produced by contraction of the sural 
muscles are generally simple, but those which result from a crushing 
of the bone are more often compound. The same remark is applicable 
also to the other bones of the tarsus, the fractures of which, being only 
produced by direct blows, are generally complicated with external 
wounds. 

Symptoms. — All fractures of the bones of the tarsus demand especial 
care in their diagnosis, since only a few of the usual signs of fracture 
are in a majority of the cases presented. The explanation of this fact 
will be found in the number, size, and strength of the bones of the 
tarsus, and in their close and firm union by ligaments, by which they 
give to each other a mutual support, so that the fracture of a single 
bone does not necessarily or usually result in displacement or deformity, 
and even crepitus is with difficulty detected ; and when we consider, 
moreover, that the fracture is generally produced by great violence, 

1 Constance, Amer. Journ. Med. Sci., vol. v. p. 222, Nov. 1829, from the Midland 
Med. and Surg. Reporter. 



FRACTURES OF THE TARSAL BOXES. 607 

directly applied, in consequence of which the foot in most cases becomes 
rapidly and enormously swollen, we shall understand the true nature of 
the difficulties which are usually presented in the way of an accurate 
diagnosis. 

Of all the usual signs of fracture, crepitus alone is pretty generally 
present, but even this often fails to tell us which bone is broken, and 
still more often does it fail to inform us as to the direction and extent of 
the bony lesions. 

If the whole or a portion of the tuberosity of the calcaneum is sepa- 
rated by the action of the muscles, and the fragment is drawn upwards, 
it may be discovered in its new position, and the heel will be flattened 
or shortened, but no crepitus can be felt unless the fragments are again 
brought in contact. 

Treatment. — Not any of the fractures of the tarsal bones in them- 
selves demand the use of splints, and it is only when complicated with a 
dislocation of the ankle and fracture of the fibula that it is proper to 
employ apparatus of this sort; certainly the exceptions to this rule must 
be very rare ; so that our practice in these cases will be confined chiefly 
to the prevention and reduction of inflammation. This will be the sum 
of the treatment demanded during the first few days after the receipt of 
the injury in probably all cases of simple fracture, and in many cases of 
compound fracture. 

If single bones, or fragments of single bones, are displaced to any 
considerable extent, and there is an external wound communicating 
with the fracture, I have no doubt it would be best in all cases to re- 
move at once by dissection the projecting bone, even although it were 
possible, or perhaps easy, to force it back again to its place, as has been 
done successfully by Ashhurst, of Philadelphia. 1 The same rule I 
would apply to examples of fractures uncomplicated with any external 
wound, if the fragments were very much displaced, and could not by 
the application of moderate force be replaced, since the bone left to 
project would prevent the patient from ever wearing a boot with com- 
fort, and would entail as much weakness upon the limb as would be 
likely to follow from its complete separation. But such cases as I have 
last supposed are exceedingly rare; indeed, I have never met with a 
simple fracture of a tarsal bone accompanied by displacement. 

Norrifl has. however, reported a case of fracture of the astragalus 
accompanied by displacement of about one-half of the bone, but with- 
out any lesion of the soft parts. This was in the person of a man set. 
30, who was admitted into the Pennsylvania Hospital on the 26th of 
Sept. 1831. " An hour previous to admission, while descending a ladder, 
he slipped and fell in such a manner as to throw the entire weight of his 
body upon the outer part of his left foot. Upon examination, the foot 
was found to be turned inwards and nearly immovable. A slight de- 
pression existed immediately below the lower end of the tibia, and there 
was ;i considerable hard and rounded projection on the outer part of the 
foot, a little below and in front of the extremity of the fibula. The skin 

1 Ashhurst, Amer. Jo urn. Med. 8ci., April, 1862. 



008 FRACTURES OF THE TARSAL BOXES. 

covering this projection was reddened, but not excoriated. There was 
no fracture of either bones of the leg." 

These appearances led Drs. Norris and Barton, under whose care the 
patient was placed, to regard the accident as a simple luxation of the 
astragalus forwards and outwards ; and a short time after admission 
efforts were made to reduce it. " This was done, after relaxing in as 
great a degree as possible the muscles of the leg, by flexing the knee, and 
1 laving assistants to keep up extension, by seizing the heel and front 
part of the foot ; at the same time the bone being pushed inwards and 
toward the joint by the surgeon. These efforts were continued for a 
considerable time, but had no effect in changing the position of the 
bone. 

" Six hours afterwards Drs. Huston and Harris saw the patient in 
consultation, when efforts were again made at reduction, which not 
proving more effectual than in the first trial, the excision of the bone 
was determined on. 

v * The patient being properly placed, an incision was made through 
the integuments, parallel with the course of the tendons, commencing 
a short distance above the projection on the foot, and extending down 
far enough to expose fairly the astragalus and its torn ligaments. The 
bone was then seized with forceps, and easily removed after the division 
of a few ligamentous fibres that continued to connect it to the adjoining 
parts. Very little hemorrhage occurred, two small vessels only re- 
quiring the ligature. 

"After removal it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and re- 
mained firmly attached to the extremity of that bone, and as it was 
judged that the efforts to remove this would be likely to produce more 
injury to the joint than would arise from allowing it to remain, no 
attempt was made to extract it. 

" The joint being carefully sponged out, the sides of the incision were 
brought accurately together by means of sutures and adhesive straps, 
after which simple dressings and a roller were applied, and the foot, 
restored to its natural situation, placed in a fracture-box." 

Subsequently that portion of the astragalus which was permitted to 
remain, having become carious and loosened, was removed also. 

The case continued to do badly ; all the bones of the tarsus, and even 
the lower ends of the tibia and fibula, becoming eventually carious ; and 
on the 27th of March, 1853, more than a year and a half after the re- 
ceipt of the injury, the leg was amputated ; but no healthy action ensued, 
and the patient soon died. 1 

The result of this case can scarcely be regarded as having settled 
anything in reference to the value of the procedure which I have recom- 
mended. For reasons which seemed satisfactory to the surgeons who 
made the operation, only one-half of the broken bone was removed ; 
whether the result would have been different if the whole had been at 
..nee taken away, we cannot now determine. 

1 Norris, Amer. Journ. Med. Sci., vol. xx. p. 379. 



FRACTURES OF THE TARSAL BOXES. 



609 



Fig. 252. 



Poinsot 1 lias reported a case in which he practised resection. An 
insane woman, set. 40, had jumped from a second floor, and was admitted 
to the Hospital St. Andre, Bordeaux. 
Poinsot readily recognized the displace- 
ment of a portion of the astragalus of the 
right foot, which was accompanied with a 
marked deformity of the foot. There was 
no external wound. The extreme tension 
of the skin over the protruding bone de- 
termined him to proceed at once to remove 
the fragment, which was composed of the 
entire body of the astragalus exclusive of 
its neck. The fragment was rotated on 
its axis, so that its articular portion was 
directed downwards and inwards, and the 
broken surface presented toward the skin. 

The neck retained its relations to the 
scaphoid. A second fracture had sepa- 
rated by arrachement that portion which 
articulates with the malleolus internus. 
Both of these latter fragments were re- 
moved, the head of the astragalus only 
being permitted to remain in place. Not- 
withstanding the utmost care to insure 
immobility, the indocility of the patient 
rendered this impossible ; inflammation and 
gangrene ensued, and on the tenth day it 
became necessary to amputate. Death 
ensued two days later. 

••Mr. Hancock 2 obtained," says Poinsot, "a magnificent result in a 
carpenter, aged 47 years, who presented a fracture of the astragalus ' at 
its inferior portion,' with displacement forwards and outwards. There 
was no wound: but the skin was so stretched on the displaced bone that 
gangrene was imminent. Mr. Hancock immediately made, by excision, 
the total extraction of the astragalus. The wound was closed and 
dressed with lint dipped in a phenic acid solution; the leg was put on 
a posterior splint with a foot-piece, and suspended in a Salter's crib. 
Phenic irrigations were made without interruption. When the first 
dressing was taken off, after eight weeks, the wound was completely filled 
up. Three months after the operation the patient could lean on the 
injured foot, and walked easily with a high-heeled boot." 

M. Poinsot, with characteristic frankness, ascribes Mr. Hancock's 
superior success to the antiseptic precautions adopted by the latter. 

A fracture of the posterior portion of the calcaneum, especially when 
it ha- been produced by muscular action, constitutes one exception to 
fractures of the tarsal bones generally, and demands usually that appa- 
ratus <»f some kind should be employed in its treatment. 




Apparatus for fracture of the poste- 
rior extremity of the calcaneum. 



Poinsot, French ed. of this treatise, \<. 699. 

k, Anat. and Sur^. of the Human Foot. London, 1873, p. 251. 

39 



610 FRACTURES OF THE TARSAL BONES. 

In order to replace the posterior fragment when displaced, or to 
maintain it in apposition until a bony union is accomplished, it may be 
necessary to shorten the gastrocnemii by flexing the leg upon the thigh 
and extending the foot upon the leg. But to retain the limb in this 
position it will be expedient always to employ apparatus. A very simple 
contrivance, however, will generally answer all the indications. A band- 
age, padded strap, or a stuffed collar may be fastened about the thigh just 
above the knee, and made fast to the heel of a slipper by a tape (Fig. 252). 
The apparatus is the same which has been recommended for a rupture of 
the tendo A chillis. 

In addition to this, the limb ought to be covered from the foot up- 
wards as far as the knee with a snug roller, underneath which, on each 
side of and above the detached fragment, ought to be placed suitable 
compresses, the object of the roller being to diminish muscular contrac- 
tion, and the compresses being intended to retain the detached piece in 
contact with the main body of the bone. Some surgeons have not found 
it necessary to flex the leg upon the thigh; but they have contented 
themselves with extending the foot upon the leg, and confining it in this 
position by a splint of wood or gutta-percha laid along the front of the 
leg, ankle, and foot. In still other cases, the fragment has shown so 
little disposition to become displaced as to render no precautions of any 
kind necessary, except to impose upon the patient complete quiet, with ' 
the limb resting upon its outside and flexed, as in Pott's fracture of the 
fibula. In this way I have once obtained a perfect union ; and in the 
case seen by Poinsot, there being no displacement of the fragment, union 
was effected while the foot was only kept at rest in a pasteboard splint. 

In case also the sustentaculum tali is torn off, the foot should be kept 
in a position of dorsal flexion. 

xlll fractures of the tarsal bones demand that as soon as the inflam- 
mation has sufficiently subsided, passive motion should be given to the 
ankle, in order to prevent, as far as possible, the anchylosis which is an 
almost constant result of these accidents. Indeed, the patient is fortunate 
who recovers a tolerable use of his foot after the lapse of many months ; 
nor can he be assured that the inflammation will leave these bones and 
their dense fibrous envelopes for a long period, and that it may not 
result in caries of more or less of the tarsal bones, demanding finally 
amputation of the whole foot. 

I have not intended to speak in this place of those severer accidents, 
accompanied with comminution and extensive laceration, which forbid 
the hope of saving the foot, and for which immediate amputation is the 
only proper resource, but which constitute, in fact, the great majority of 
all the fractures of the tarsal bones. 



FRACTURES OF THE METATARSAL BOXES. 611 



CHAPTER XXXV. 

FRACTURES OF THE METATARSAL BOXES. 

These bones can scarcely be broken except by direct blows, and the 
great majority of their fractures are the results of severe crushing acci- 
dents, such as render amputation sooner or later necessary. Of those 
which do not demand amputation, by far the largest proportion are com- 
pound fractures ; of which class the following example will serve as an 
illustration : 

A man in the employ of one of the railroads which connect with this 
city was run over by a loaded car on the 14th of June, 1856, crushing 
his right arm so as to render its immediate amputation necessary. I 
found also a compound comminuted fracture of the fourth metatarsal 
bone of the right foot. Considerable hemorrhage occurred from the 
wound, but this ceased spontaneously. Cool water-dressings were dili- 
gently applied, without splints or bandages, and although some inflam- 
mation and suppuration ensued, the parts finally healed over and the 
fragments united, with only a slight backward displacement at the seat 
of fracture. 

When only one bone is broken, the displacement is usually very 
trivial : but when several are broken, it may be considerable. Mal- 
gaigne relates an example of this latter accident in which, the three 
middle bones being broken by the wheel of a carriage, and the integu- 
ments being badly torn and bruised, it was found impossible to retain 
the fragments in place. The patient recovered, and was able to place 
the foot well to the ground, but the proximal fragments continued to 
project upwards upon the top of the foot to such a degree as to require 
a special shoe. 

In a majority of cases the direction of the displacement is backward^ 
(upwards), especially when the middle metatarsal bones are the subjects 
of the fracture. 

I have in my cabinet a second metatarsal bone broken obliquely near 
its middle, with only a very slight displacement of the lower fragment 
backwards; and also the cast of a bone which has united with an enor- 
backward projection. 

In one instance I have seen the metatarsal bone of the little toe cut 
in two with an axe, and the fragments united in about thirty days, but 
with the lower fragments slightly displaced outwards. 

Delamotte relates ;i case also in which the first four metatarsal bones 
wen- cut off", and complete union was accomplished on the fortieth day; 
at the end of two month- the patient walked without lameness. 

Treatment. — If the fragments are not displaced, nothing is required 
except that the foot shall be kept ;it rest, and the inflammation controlled 
by suitable mea 



612 FRACTURES OF THE PHALANGES OF THE TOES. 

In case, however, a displacement exists, it ought to be remedied, if 
possible, since, if only very slight, it may become the source of a serious 
annoyance. If the fragments project upwards, they interfere with the 
wearing of a boot, and if they sink toward the sole, the skin beneath is 
liable to remain constantly tender, and the patient may thus be seriously 
maimed for life. 

In ease the displacement is not due to the action of the muscles, but 
only to the nature and direction of the force producing the fracture, or 
to entanglement of the broken ends, and it is likely to cause any of the 
inconveniences which I have mentioned if permitted to remain, it will be 
advisable at once to employ considerable force in the way of pressure, or 
to elevate the fragments through an opening previously made upon the 
dorsum of the foot, calling to our aid even the saw or the bone-cutters, 
if necessary. After which the fragments may be retained in place by 
carefully applied pasteboard splints and compresses. 



CHAPTER XXXVI. 

FKACTURES OF THE PHALANGES OF THE TOES. 

If fractures of the other bones of the feet are generally of such a 
character as to require immediate amputation, these fractures demand 
this extreme resort still more often. Our experience, therefore, in the 
treatment of fractures of the phalanges of the toes is extremely limited. 

Lonsdale observes that it is not uncommon to find great irritation arise 
after fracture of the great toe ; an inflammation extending along the ab- 
sorbents on the inside of the leg to the groin, causing abscesses to form 
in different parts of the limb, and producing sometimes great constitu- 
tional disturbance. An illustrative case has come under my own obser- 
vation at the Buffalo Hospital of the Sisters of Charity. The patient, 
Morgan McMann, set. 18, was admitted Dec. 23, 1853, having several 
day- before received an injury upon the great toe, which contused the 
flesh severely and broke the first phalanx. He was then suffering from 
severe pain in the foot and leg, and the absorbents were inflamed quite 
to the groin. Poultices being applied to the foot and cool lotions to the 
limb, the inflammation soon subsided, but not until a portion of the toe 
had sloughed away. Eventually also it became necessary to remove 
some portion of the phalanx, which had died ; after which the wounds 
healed kindly. 

When any of the smaller toes are broken, it will be found easier to 
support the fragments by a broad and long splint which shall cover the 
whole sole of the foot and all the toes at the same time, than to attempt 
to apply a splint to the broken toe alone. If, however, we prefer this 
latter mode, a thin piece of gutta percha will be found altogether the 
most convenient material for the purpose. 



GUNSHOT FRACTURES. 613 

If the great toe is broken, its great breadth may prevent any dis- 
placement, and a well-moulded gutta-percha splint will generally secure 
a perfect and rapid union. 



CHAPTER XXXVII. 

GUNSHOT FEACTUKES. 

Gunshot fractures have already been considered, more or less in 
detail, in the several portions of this work, wherever it seemed to be 
necessary to call especial attention to them. This chapter will be de- 
voted, therefore, to a brief resume of my own observations and conclu- 
sions in this department; to which will be added a few general statistical 
statements, drawn chiefly from the published records of the late war. 

Causes. — Gunshot fractures are caused by a great variety of missiles, 
such as musket and rifle balls, solid shot and shell, grape, canister, 
Shrapnel, chain and bar shot, fragments of iron, stone, splinters of wood, 
etc., etc. The only qualities which these missiles possess in common is, 
that they are all projected by the elastic power of gunpowder, and gener- 
ally strike the body with great force; and that they cause fractures by 
direct violence — seldom, if ever, by counter-stroke. 

Round, smooth balls frequently impinge upon bones without causing a 
fracture, for the reason that they are easily deflected; and this happens 
especially when they are not moving with great velocity. 

Conical rifle-balls seldom fail to fracture the bones which lie in their 
direct course: never, perhaps, when, at the moment of contact, the ball 
is moving with its average velocity. The peculiar destructiveness of this 
missile is due to its weight, momentum, and form. 

Canister, grape. Shrapnel, solid shot, shells, chain and bar shot, are 
still more destructive; generally tearing the limbs from the body in such 
a manner us to render readjustment and restoration impossible. 

Pathology. — These fractures may be simple, compound, comminuted, 
or complicated : and in addition to these common varieties of fractures 
there is occasionally presented an example of simple " perforation.'" or 
mere penetration of the bone without fissure or other fracture; and still 
more frequently are seen examples of perforation with fissures. 

Probably ninety-nine per cent, of all gunshot fractures are both com- 
pound and comminuted ; the comminution being, in general, excessive. 

A- in gunshot wounds of the soft parts it lias been generally observed 
that the point of entrance is more round, more smooth, and somewhat 
smaller than the point of exit, and that the tissues are a little depressed 
at the entrance, while they are slightly protruded at the exit; so also in 
gunshot fractures it will often be found that the side of the hone on which 
the ball has entered, or upon which it firsl impinged, is less comminuted 
than the opposite side; and, if it is a "perforation," thai the opening i- 
smaller upon the one side than upon the ether: that the edges are 



614 GUNSHOT FRACTURES. 

slightly depressed upon one side, and elevated or protruded upon the 
other; and. finally, that numerous small, as well as some large, frag- 
ments of bone have been carried into that portion of the track of the 
wound which lies between the bone and the point of exit of the missile. 

When a ball fractures the shaft of a long boiwfc although the blow may 
have been received three, four, or even six inches from an articulation, 
the comminution or a single longitudinal fissure may sometimes be found 
extending into the joint. These fissures or splittings of the shaft often 
extend also a long distance up or down, without terminating in the joint. 

Perforations without fissure occur most often in the broad bones of the 
pelvis, in the scapula, or in the spongy extremities of the long bones. 
In the latter, however, it is exceedingly rare to find perforation without 
fissure. 

Perforations with fissure are pretty common in the head of the humerus 
and in the head of the tibia ; they occur also, but less often, in the lower 
ends of the femur and tibia, in the trochanteric portion of the femur, 
and in the head of the femur. I wish to be understood to say that 
fissures occur less often at the points last mentioned, simply because 
perforations are there less common. It should be known that if perfora- 
tions do occur at these points, a splitting or fissure communicating with 
the joints is almost inevitable. A misunderstanding here would lead to 
a very fatal error in many cases. 

Prognosis. — In general it may be stated that gunshot fractures of the 
upper extremities do not demand amputation, and that similar injuries 
in the lower extremities do demand amputation. 

This statement is very broad, and cannot be understood except by a 
consideration of these accidents somewhat in detail. Thus: 

Gunshot fractures of the clavicle, scapula, of the shaft of the humerus, 
of the shafts of the radius and ulna, and of the carpal, metacarpal, and 
phalangeal bones, notwithstanding these bones have suffered extensive 
comminution, do not usually demand amputation ; they will in most cases 
eventually unite, and give to the patients tolerably useful limbs. If, 
however, at the same time that the shaft of the humerus, or of the radius 
and ulna, is thus broken, the large nervous trunks are torn asunder, so 
that the extremity is cold and insensible, the limb cannot probably be 
saved, nor, if it could be, would it be of any value. Destruction of the 
main artery supplying the limb diminishes the chance of its being saved, 
but does not, in the case of the upper extremities, necessarily demand 
amputation. 

Penetration of the shoulder-joint by a musket or rifle ball, producing 
a fracture of the head of the humerus or of the glenoid cavity of the 
scapula, demands amputation when either the axillary artery or axillary 
nerves are injured; but resection can generally be practised with a rea- 
sonable chance of success when the arteries and nerves are untouched. 
Resection is al><> made successfully at the shoulder-joint in some cases 
where larger missiles have traversed the joint, such as canister, frag- 
ments of shell, etc. 

Penetration of the elbow-joint by a large shot, or by a Minie rifle- 
ball, the missile fairly entering or traversing the joint, demands amputa- 
tion when the main arterial and nervous supplies are cut off, and resection, 



GUNSHOT FRACTURES. 615 

generally, when both remain uninjured. Resection may be attempted at 
the elbow-joint, also, in some cases where, the nervous supply remaining 
good, only one of the principal arterial trunks is cut off. 

Frequently a ball strikes the outer or inner condyle of the humerus, 
making but a small opening into the joint, and producing only slight 
comminution, and in such cases we often save the limb with more or less 
anchylosis, and without resection. 

The remarks which have been made in reference to gunshot fractures of 
the elbow-joint apply, almost without qualification, to the same accidents 
at the wrist-joint. 

For gunshot wounds with fracture of the carpal, metacarpal, and 
phalangeal bones neither resection nor amputation is often required, 
unless the soft parts are almost completely torn away. 

The prognosis which, as we have now seen, is so favorable in the 
upper extremities, will be found very different in the lower extremities ; 
indeed, it is almost reversed. Thus: 

Gunshot fractures of the shaft of the thigh, of the shafts of the tibia 
and fibula, and of the tarsal bones, generally demand amputation; or, 
to be more precise, gunshot fractures of the head and neck of the femur 
almost always terminate fatally under amputation or excision, and equally 
under treatment as fractures, that is, where an attempt is made to save 
the limb without interference with the knife. The same accidents in the 
upper third of the shaft of the femur are generally fatal; but if the 
main artery and the principal nerves are uninjured, the life is, in general, 
less hazarded by an attempt to save the limb than by amputation. In 
the middle third, under the same circumstances, the chances may be con- 
sidered equal, as between amputation and the attempt to save the limb 
by apparatus ; in the lower third the chances are in favor of amputation. 

The above statements in relation to fractures of the femur are based 
mainly upon my own experience, and have been carefully considered. 

I have seen no resections of the knee-joint, and but few of the shaft 
of the femur, after gunshot fractures, which have not terminated fatally ; 
and I am convinced that they should never be attempted in fractures of 
the thigh, unless it be that case which presents so little hope in any 
direction, viz., gunshot fracture of the head or neck of the femur. 

Gunshot fractures of the shafts of both tibia and fibula demand ampu- 
tation where the comminution is extensive, or the pulsation of the pos- 
terior tibial artery is lost, or the foot is cold and insensible. It is not 
intended to say that some limbs thus situated have not been saved, but 
only that the attempt to save such limbs greatly endangers the life of 
the patient, while amputation at or below the knee is relatively safe. 

Amputation is the only safe expedient in deep penetrating wounds of 
the tarsal bones produced by missiles of the size of musket-balls or larger. 
Tli'- only exceptions, which fan safely be made, are in cases where balls 
have opened partially and superficially these articulations. 

Resection- at the ankle-joint are much more hazardous than amputa- 
tion.-, and scarcely to bo preferred, in army practice, to attempts to save 
the foot without surgical interference. 

Treatment. — While considering the prognosis in these accidents, I have 
necessarily spoken of the treatment in certain cases; especially with a 



616 GUNSHOT FRACTURES. 

view to the propriety of amputation or resection. It remains only to 
speak briefly of the treatment of those cases in which we may attempt 
to save the limb without -resection, properly so called; for we must not 
forget that pretty often Ave find it necessary to remove small, loose frag- 
ments of bone by the finger, or by the aid of the knife, or to resect sharp 
points with the saw or the bone-cutters, when w r e do not practise "resec- 
tion," in the sense in which this term is usually employed by surgical 
writers. 

I shall take the liberty, in this connection, of reproducing what I have 
written elsewhere in relation to gunshot fractures, since it comprises 
nearly all that seems necessary to be added upon this subject. 1 

" If an attempt is made to save a limb badly lacerated and broken, 
certain conditions in the treatment are necessary to success. 

"All projecting pieces of bone which cannot be easily replaced and 
are not firmly attached to the soft parts, must be at once cut or sawn 
away. 

"All foreign substances, such as fragments of balls or other missiles, 
pieces of cloth, wadding, dirt, etc., must be removed. 

" Any portions of integument, fascia, or muscles, which are entangled 
in the wound, and prevent a thorough exploration, or may obstruct the ' 
free escape of blood or of matter, must be freely divided. 

"Counter-openings must be made at once, or at an early period after 
the formation of matter, to insure its easy escape (and in certain cases 
a drainage-tube must be carried through both wounds). 

" The limb must be placed in an easy position, and not confined by 
tight bandages or forcibly extended by apparatus. 

"The inflammation must be controlled by constitutional and local 
means, and especially by the use of water lotions whenever their em- 
ployment is practicable." 

Fig. 253.- 



Author's movable canvas. 



If joints are implicated Beriously, and an attempt is still made to save 
the limb, the joint surfaces must be laid freely open, so as to prevent all 
possibility of the confinement of blood, serum, or pus; and the joint 

1 Treatise <>u Military Surgery, by Frank Hastings Hamilton. 1 vol., 8vo. Pub- 
I by Baillidre Brothers. New York, 1861; also enlarged ed. of same work in 1865. 



GUXSHOT FRACTURES. 



617 



must be placed perfectly at rest, without adhesive strips, bandages, or 
any apparatus which shall compress the limb or embarrass its circulation. 
! do not know that it is necessary to speak more particularly of the 
treatment of gunshot fractures, unless it be to say that I still give the 
preference, in fractures of the femur, to the straight position. In most 
cases I have preferred my own apparatus, already described when speak- 
ing of fractures of the thigh in general, with moderate extension ; and 
by moderate extension is to be understood such as may be effected with 
from five to ten pounds. 

Fig. 254. 




x \^^ : ^#V i ^_u^ i AW ^ . „ 




^i^^o-L^-^-^^— "■ 




Movable canvas, with extension, on " horses." 

A movable canvas, such as is shown in the accompanying woodcuts 
with a hole in the centre, and reinforced by an additional piece of canvas 
where the weight of the hips rests, will enable the surgeon to move his 
patient and clean the bed when necessary. The standard which supports 
the pulley can be received in a slot in the frame. 

An apparatus similar to this was used, during our late war, in the 
Lincoln General Hospital at Washington. 

I have also used, with the movable canvas, and upon an ordinary 
bed. Hodgen's apparatus, or "cradle," as he terms it, and have found it 
exceedingly useful, and much preferable to any form of double-inclined 
plane, whether suspended or not. The cradle is simply a skeleton-box, 
of the length of the thigh and leg, made of light strips of wood. Across 
the two upper bars are laid, transversely, cloth bands, upon which the 
limb i» laid at full length. 1 

Of gunshot fractures of the femur many hundreds, probably many 

thousands, during and Bince tin- close of our civil war, have come under 

my observation; but of these, only ''2 have been made the subject of 

rial rcr-ord. Of this number, 75 were fractures of the shaft of the 

femur; 9 being fractures of the upper third ; 36 of the middle third: and 



1 IT dgen, Treatise on Military Surgery, by the autho 



108. 



618 



Q UNSHOT FRACTURES. 



30 of the lower third. Nearly all of these fractures were caused by the 
conical rifle-hall. They were treated in various Federal and Confederate 
hospitals by a great variety of methods, and under a variety of circum- 
Btances, which latter were sometimes favorable and sometimes unfavor- 

Fig. 255. 




Fig. 256. 




Hodgen's apparatus for gunshot fractures of the thigh. 

able. The results may, therefore, be regarded as furnishing a fair basis 
for conclusions as to what may reasonably be expected in army surgery, 
or during the progress of a great war. I have a strong conviction, how- 
ever, that if in an equal number of cases the straight position, with 
moderate extension, were to be employed, and the circumstances were as 
favorable as are usually found in civil hospitals, the results would be 
considerably better than are here shown. Indeed, my own recorded 
cases show, in a marked degree, the advantages of the straight position, 
with slight extension, over the double-inclined planes. In a number of 
these cases, while the limb was flexed, the shortening and bending were 
excessive, and the substitution of Buck's apparatus, Hodgen's, or my 
own, has made at once a great improvement in both regards, besides 
contributing manifestly to the comfort of the patients. 

The average shortening, in those fractures of the shaft of the femur 
which were measured by myself after union was effected, was, in the 
upper third, two inches and one-eighth ; in the middle third, two inches 
and one-quarter : ami in the lower third, a little more than one inch and 
a half. In the upper third three were shortened two inches or more; 
the greatesl shortening being three inches and one-quarter. In the 
middle third, twenty were shortened two inches or more, six three inches 
or more, two four and a half*, and -one five inches. In the lower third, 
two were shortened two inches or more; the greatest shortening being 
two inches and three-quarters. 

In a large proportion of the cases the thigh was bent at the point of 



GUNSHOT FRACTURES. 619 

fracture, the bend being in most cases outwards, or to the fibular side of 
the limb. "Where N. R. Smith's suspension apparatus was used, the 
bend was usually backwards, while in most of the cases treated in the 
straight position, with moderate extension, the limb was nearly or quite 
straight. 

It is somewhat remarkable that in this table of ninety-two cases there 
are only three examples of union delayed beyond four months, and one 
of these patients was evidently about to die. In a pretty large propor- 
tion of cases the union was not delayed much beyond the usual period of 
union for a simple fracture, although the limb might be much shortened 
and crooked, and still discharging pus, with fragments of bone occa- 
sionally. 

Among the cases which have come under my especial notice are a few 
of peculiar interest, and which deserve to be particularly mentioned. 

Limb Lengthened. — Melchior Brietel, private 12th N. Y. Volunteers, 
was wounded in June, 1862, at the battle of White Oak Swamp, Va., 
by the fragment of a shell, which struck the left leg three inches above 
the condyles. He was taken to Richmond as a prisoner, and about a 
month later he was exchanged and sent within our lines. January 1, 
1864, I found him in the United States General Hospital at Newark, 
under the charge of Surgeon Taylor. The wound was still discharging 
matter occasionally, and several fragments of bone had been removed. 
Splints were not applied until after his exchange. No extension was 
ever employed. At the end of four months he began to walk about 
with crutches. 

On measuring I found this limb lengthened half an inch, and this 
measurement was confirmed by Surgeon Taylor and others. There was 
no anchylosis at the knee-joint. 

It is doubtful whether, in this case, the shaft was broken across en- 
tirely ; if it was, probably no displacement ever occurred. The most 
reasonable supposition is that the fragment of shell entered the bone, 
and that it was in the bone at the time of my last examination, and that, 
in consequence of its presence, the bony structure had become liyper- 
aemic, and had undergone hypertrophy in the direction of the axis of the 
limb. 

Perforating and Penetrating Wounds of the Femur. — James S. 
Mussey, of 16th X. Y. Volunteers, Avas wounded at Gaines's Mill, June 
27. 1862, probably by a round ball. The ball entered the right nates 
from behind, passing entirely through the right trochanter ; a finger 
could he thrust through the round, smooth hole in the bone. When I 
saw him, three months after the accident, al Baltimore, under the care 
of Surgeon Hasson, the wound was still discharging pus, but in no other 
way was the injury causing either local or general disturbance 

At the Bame time, also, my attention was called to the case of Henry 
Voger, 20th Mass. Volunteers, who was wounded. .June 30, 1862, at the 
battle of White Oak Swum]). Va. A hall had entered the lower end of 
the femur, near the joint, in front, hut did not pass through, and had 
not. up to this time, been found. Three months had passed since the 
injury was received, and the wound was now entirely closed, the knee- 
joint being anchylosed : but in other respects the condition of the limb 



620 GUNSHOT FRACTURES. 

was almost normal. At no time was there much inflammation of the 
soft parts in the neighborhood of the injured structures. 

Sergeant Lewis Monell, of the 119th N. Y. Volunteers, was wounded 
July 1. 1863, by a ball, which entered on the outside of the left thigh, 
within one inch of the lower end of the femur, passing forwards, and 
emerging in front above the patella. Four months after the accident I 
found him at the Fifty-first Street United States General Hospital, New 
York City. Several fragments of bone had escaped; the limb was bent 
to an acute angle, and pus was still discharging from the wound. There 
was no effusion into the joint, and his ultimate recovery seemed to be 
assured. 

H. 0. C. was a private in the French army in the Crimea,, when he 
was wounded in his left leg by a ball which passed through the bone 
from before backwards just above the patella. Synovia with pus dis- 
charged for several months, and three small fragments of bone escaped. 
In seven months the wound became permanently closed. When I exam- 
ined the limb in 1864 the joint was a little deformed, and slightly anehy- 
losed. but in other respects sound. 

These examples of recovery after gunshot injuries of the femur in the 
vicinity of the knee-joint must be understood to constitute rare excep- 
tions to the rule. In most cases such perforations have been accom- 
panied with longitudinal fissures involving the joint, as is illustrated in 
Fig. 1 of this volume ; and attempts to save the limbs have resulted in 
the loss of the lives of the sufferers. 

Fracture from Duelling Pistol ; Recovery ivithout Lameness. — In 
the somewhat famous duel fought between J. C. Breckenridge and 
Frank Leavenworth, on Navy Island, June 7, 1855, with duelling pis- 
tols, at ten paces, Breckenridge was shot in the calf of the leg, and 
Leavenworth through both thighs. After Leavenworth fell he was 
carried in a small boat to a point known as Fort Schlosser, on the 
American side of the Niagara River, and placed in a wooden cabin, the 
only tenement in the place. I was at once summoned, but did not 
reach there until the following day. Drs. Grimes, Church, and Ware 
were already present. We found that the bullet had entered his right 
thigh about eight inches above the knee, and passed through the limb 
in front of the bone. The ball then entered the left thigh a little 
farther hack and a little lower down, striking the femur and breaking it 
about five or six inches above its lower end. Here the ball was arrested, 
probably being deflected and becoming lodged in the flesh, and it was 
never found : nor did it ever afterwards cause any trouble. 

I visited Leavenworth, in consultation with Drs. Ware and Church, 
once or twice each week until his recovery was complete. During the 
first few days no apparatus was applied, but the broken limb was sup- 
ported by junks, and both limbs w r ere kept cool and moist with evapo- 
rating Lotions. On the eight day a long side-splint was applied 
( Boyer's), with a perineal band for counter-extension, and a screw for 
extension. The amount of extension was varied from day to day. hut 
it was never more than could he comfortably borne. Still later, short 
side or coaptation splints were applied. At the end of eight weeks the 
long splint or extending apparatus was removed, and a few days after 



GUNSHOT FRACTURES. 621 

the coaptation splints. Eleven weeks after the accident he was on 
crutches. The femur was then found shortened half an inch, and per- 
fectly straight. 

Mr. Leavenworth survived this injury many years, and, although he 
led a very active life, he never suffered any inconvenience from the 
wounds in either limb, and his gait was perfect. 

It is probable that in this case there was no comminution of the bone ; 
and I think the same thing has happened under my observation several 
times, where the femur has been broken by a round ball, or by a conical 
ball whose force was nearly expended. A conical ball at short range, 
when it strikes the shaft of the femur fairly, can never fail to cause 
extensive comminution. 

Missiles remaining in the Bone. — Lieutenant Champlain (subsequently 
Commodore) was wounded by a bullet, in 1813, during a sortie from 
Fort Erie, on the Niagara frontier. The ball entered about the middle 
of his thigh and buried itself in the bone. Subsequently Dr. William 
Gibson, of Philadelphia, and, still later, Dr. Nathan Smith, of New 
Haven, attempted the removal of the ball, but without success. 

During all of his long and active life his limb continued to give him 
serious trouble at intervals, and I was several times called to open ab- 
scesses which had suddenly formed, but I was never able to find the ball. 
The limb was firm, somewhat shortened, and strongly rotated outwards 
at the point of fracture. 

Lieutenant Charles Payson, aide-de-camp to General Devins, was 
wounded by the fragment of a shell while leading a charge upon a 
portion of the enemy's lines at the battle of Cold Harbor, Va., June 
1, 1864. 

The missile entered about the middle of the left thigh, breaking and 
comminuting the bone. Surgeon Rice, of the 25th Mass. Volunteers, 
removed on the same day one fragment of bone about two inches in 
length by half an inch in breadth, but the piece of shell could not be 
found. On the third day he was taken to Chesapeake Hospital, near 
Fortress Monroe. Subsequently the surgeon in charge removed with a 
saw portions of both fragments. 

October 24th, nearly five months after the receipt of the injury, I 
was summoned to the hospital to see Lieutenant Payson in consulta- 
tion. I found the limb suspended in Smith's anterior splint, the two 
separated ends of the broken femur pointing backwards at an angle of 
45°, and nearly projecting from the wound. This is the position which 
I have seen the fragments take in very many, probably in a majority, 
of the gunshot fractures of the shaft of the femur treated by this ap- 
paratus; and which vicious position the surgeon had in vain sought to 
prevent in the case of Lieutenant Payson. 

Having removed three or four detached fragments of dead bone, we 
laid the limb in a straight position upon a Hodgen's splint or cradle, 
while permanent extension was made with a weight and pulley secured 
to the leg by adhesive strips. The amount of extension employed was 
eight pounds. The fragments were now in line, and the patient declared 
that he was much more comfortable. 

March 31, I860, five months after this change in the mode of dressing 



622 GUNSHOT FRACTURES. 

lias beeD adopted, he was brought to New York greatly improved in 
health, the bone firmly united, with a slight outward bend at the seat of 
fracture, and shortened six and a half inches, and with almost complete 
anchylosis of the knee-joint. 

From this time Lieutenant Payson remained constantly under my 
charge for two or three years, when at length the wound became per- 
manently closed, and his health was completely reestablished. In the 
meanwhile, however, after his return, to New York, the original wound 
discharged more or less constantly, and occasionally abscesses of con- 
siderable size were formed which had to be opened. On the 8th of No- 
vember. 1865, seventeen months after the wound was received, it was 
my good fortune to detect the position of the fragment of shell which 
had caused all this trouble. I had searched for it many times before, 
but on this occasion a Nelaton's probe disclosed an iron-rust mark by 
which I was guided to its bed in the centre of the bone, and from which 
it was at once removed. 

As supplementary to this chapter, it seems proper to add a brief 
resume of the statistics of the late civil war, drawn from the reports of 
the Surgeon-General, made in 1865 and in 1867. 1 

Of 4167 gunshot wounds of the face, 1579 were accompanied with 
fractures of the facial bones. Of these latter, 107 died, and 891 re- 
covered. The remainder are undetermined. Secondary hemorrhage is 
said to have been the most frequent cause of death. 

Of 187 examples of gunshot injuries of the spine (not including those 
in which the chest or abdomen was penetrated), 180 died. Six of those 
reported as having recovered were examples of fracture of the transverse 
or spinous processes. The seventh is that of a soldier wounded at Chick - 
amauga, September 20, 1863, by a musket-ball, which fractured the 
spinous process of the fourth lumbar vertebra, and penetrated the verte- 
bral canal. The ball and fragments of bone were extracted, and one 
year after he was reported as "likely to recover." 

(President James A. Garfield was shot by the assassin Guiteau, July 2, 
1881. The weapon employed being a "bulldog" pistol of large size,- 
which was fired at short range, the ball entering his body on the right 
side, about three and one-half inches from the spine. Its direction, after 
penetrating the muscular parietes, could not be determined. Immedi- 
ately upon receipt of the injury he complained of sharp pains in his 
right foot and ankle, and later he felt similar pains in the left ankle, 
with slight pains in the right scrotum. These pains gradually subsided, 
and after a few <lavs disappeared altogether. Beyond this there was 
never at any time a symptom pointing to an injury of the spine. No 
degree of paralysis over ensued. President Garfield died September 19, 
1881, eleven weeks after the receipt of his injury. The autopsy dis- 
closed the following facts: 

The ball, after penetrating the thoracic Avail at the tenth intercostal 
-pace, and fracturing the adjacent ribs, passed through the connective 
tissue and fat behind the upper edge of the right kidney, without 
wounding the liver, perforated the psoas fascia, and the psoas magnus 
muscle near its attachment to the first lumbar vertebra, and penetrated 

1 Circular No. 6 Surgeon-General's Office; also Circular ]S"o. 7. 



GUXSHOT FRACTURE^ 



623 



the first lumbar vertebra in the upper part of the right side of its body. 
The aperture by which it entered the vertebra involved the intervertebral 
cartilage next above, and was situated just below and anterior to the in- 
tervertebral foramen, from which its upper margin was about one-quarter 
of an inch distant. Passing obliquely to the left and forwards through 
the upper part of the body of the first lumbar vertebra, the bullet 

Fig. 257. 



^ 




2d lumbar. 






Course of the ball through the first lumbar vertebra, its direction being indicated by 
the probe. 

Fig. 258. 




Same specimen sawn open. 

emerged by an aperture, the centre of which was about half an inch to 
the left of the median line, and which also involved the intervertebral 
cartilage next above. The cancellated tissue of the body of the first 
lumbar vertebra was very much comminuted and the fragments some- 



624 GUNSHOT FRACTURES. 

what displaced. Several deep fissures extended from the track of the 
bullet into the lower part of the body of the twelfth dorsal vertebra. 
Others extended through the first lumbar vertebra, into the intervertebral 
cartilage between it and the second lumbar vertebra. Both this cartilage 
and that next above were partly destroyed by ulceration. A number of 
minute fragments from the fractured lumbar vertebra had been driven 
into the adjacent soft parts. 

It was further found that the right twelfth rib also was fractured at a 
point one inch and a quarter to the right of the transverse process of the 
twelfth dorsal vertebra; this injury had not been recognized during life. 

On sawing through the vertebra, a little to the right of the median 
line, it was found that the spinal canal was not involved by the track of 
the ball. The spinal cord and other contents of this portion of the 
spinal canal presented no abnormal appearances. The rest of the spinal 
cord was not examined. 

Beyond the first lumbar vertebra the bullet continued to go to the left, 
passing behind the pancreas to the point where it was found. Here it 
was enveloped in a firm cyst of connective tissue, which contained be- 
sides the ball a minute quantity of inspissated, somewhat cheesy pus, 
which formed a thin layer over a portion of the surface of the lead. 
There was also a black shred adherent to a part of the cyst-wall, which 
proved on microscopical examination to be the remains of a blood-clot. 
For about an inch from this cyst the track of the ball behind the pan- 
creas was completely obliterated by the healing process. Thence, as far 
backward as the body of the first lumbar vertebra, the track was filled 
with coagulated blood, which extended on the left into an irregular space 
rent in the adjoining adipose tissue behind the peritoneum and above the 
pancreas. The blood had worked its way to the left, bursting finally 
through the peritoneum behind the spleen into the abdominal cavity. 
The rending of the tissues by the extravasation of this blood was un- 
doubtedly the cause of the paroxysms of pain which occurred a short 
time before death. 

The fatal haemorrhage proceeded from a rent nearly four-tenths of an 
inch long in the main trunk of the splenic artery, two inches and a half 
to the left of the cceliac axis. This rent must have occurred at least 
several days before death, since the everted edges in the slit in the vessel 
were united by firm adhesions to the surrounding connective tissue, thus 
forming an almost continuous wall bounding the adjoining portion of the 
blood-clot. Moreover, the peripheral portion of the clot in this vicinity 
was disposed in pretty firm concentric layers. It was further found that 
the cyst below the lower margin of the pancreas, in which the bullet 
was found, was situated three inches and a half to the left of the cceliac 
axis. 1 ) 

■ official report of the autopsy; made at Elberon, Long Branch, N. J., Sep- 
tembei 20, 1881, eighteen hours after death, by D. S. Lamb, of the Army Medical 
Museum, Acting Asst. Surgeon U. S. Army, in the presence of the attending phy- 
sicians and surgeons — Joseph K. Barnes, Surgeon-General U. S. Army; J. J. Wood- 
ward, SurgeoE U. 8. Army: I). W. Bliss, M.D. ; Kobert Reyburn, M.D. ; and of 
the consulting surgeons — I). Hayes Agnew, M.D., and Frank H. Hamilton, M.D. 

The report was signed also by Andrew H. Smith, M.D., who was present as a 
representative of the coroner of the State of New Jersey. 

>lso, the author's summary of the President's case, Med. Gaz., Oct. 1881. 



GUNSHOT FBACTUSES. 625 

Of 359 gunshot wounds of the pelvis (not including those in which 
the abdominal cavity was penetrated). 77 died and 97 recovered. In the 
remainder the result is not ascertained. In 256 cases the ilium alone 
was injured : in 19, the ischium alone : in 12, the pubes : in 32, the 
sacrum : and in 40 cases the lesions extended to two or more portions of 
the innominata. Pyaemia was a frequent cause of death. 

Of 1689 gunshot fractures of the humerus, 436 died, and 1253 recov- 
ered. Xine hundred and ninety-six of these 1689 cases were treated by 
amputation or resection, with a mortality of 21 per cent. In 693 cases 
the conservative treatment was adopted, with a mortality of 30 per cent. 

Of 68 cases in which attempts were made to save the limb after gun- 
shot injury of the hip-joint, without resection, all died. (I have seen two 
cases of successful treatment of these accidents by the conservative plan, 
and others have been reported.) 

Fifty-three amputations at the hip-joint, made by surgeons in the Fed- 
eral and Confederate armies, including also reamputations, gave seven 
successful results. The fate of two is uncertain. 

Sixty-three excisions at the same joint, made by Federal and Confed- 
erate surgeons, furnished five successful cases. 

Three hundred and thirty cases of gunshot fracture of the upper third 
of the femur, in which neither amputation nor resection was practised, 
gave a mortality of 71.81. Thirty-two cases in which amputation was 
made gave a mortality of 75 per cent. Twenty-two in which resection 
was made, gave a mortality of 81.18. (I have rejected three cases 
given in the report as cured. Two of these were resections of the head, 
and one was merely a " rounding off of sharp edges.") 

Two hundred and thirty-two cases of gunshot fractures of the middle 
third, treated without amputation or resection, gave a mortality of 55.46. 
Ninety-three treated by amputation gave a mortality of 54.83. Fifteen 
treated by resection gave a mortality of 86.66. 

One hundred and seventy-three gunshot fractures of the lower third, 
treated without amputation or resection, gave a mortality of 57.79. Two 
hundred and forty-three amputated — mortality 46.09. Two resected — 
both died. 

Of 308 gunshot wounds of the knee-joint, with or without fracture, 
treated without amputation or resection, 258 died — mortality 83.76. Of 
the 50 which recovered there were, however, only six or eight in which 
the testimony is unequivocal that the joint was opened. Of 452 ampu- 
tated. 331 died — mortality 73.23. Of 10 resected, 9 died — mortality 
90 per cent. 

Of 696 gunshot fractures of the leg, 169, or 24 per cent., were fatal. 

N ■■ alysee have been made of fractures of the smaller bono. 

It is much to be regretted that in these comparative analyses of the 
treatment of gunshot fractures, except in the case of the hip-joint, by 
the three methods, it i> not stated whether the amputations or resections 
were primary or secondary. In all secondary amputations and resec- 
tion-, which, for aught that appears, may have constituted a majority of 
the whole number, the conservative treatment had been tried and had 
failed, and the deaths which followed ought in justice to be charged to 
conservatism, and not to the operation. As the reports now stand, they 

40 



626 



GUNSHOT FRACTURES. 



are of little or of no importance in determining the relative value of con- 
servative and operative treatment. 

From the reports of the Confederate army, as published in the Con- 
federate States Medical Journal we learn that of 221 cases of gunshot 
fractures of the thigh, treated without amputation or resection, 105 died 
and 116 recovered. The shortest period of recovery was 41 days ; the 
longest, 255 days ; the average, 104 days. The shortest period of fatal 



Fig. 259. 



f 



Fig. 260. 








Gunshot fracture of thigh. (Author's collection.) 
Side view. Front view. 

termination was one day ; the longest, 185 days ; average, 52 days. 
Greatest shortening, five inches ; least, half an inch ; average, one inch 
and nine-ten th-. 1 

Of 507 amputations for gunshot fractures of the thigh, 250 recovered. 2 



1 Richmond Med. Journ., Feb. 1866. from Confederate States Med. Journ. 
- Ibid., January, 1866, p. 52. 



PART II. 



DISLOCATIONS 



DISLOCATIONS. 



CHAP TEE I. 

GENERAL CONSIDERATIONS. 

§ 1. General Division and Nomenclature. 

A dislocation is the displacement of one bone from another bone or 
cartilage at the place of natural articulation. 

Dislocations may be divided into accidental or traumatic, spontaneous 
or pathologic, and congenital. 

Our remarks upon the etiology, pathology, symptomatology, prognosis, 
and treatment of these injuries must be considered as applicable only to 
accidental or traumatic dislocations, unless the fact is in any case other- 
wise stated. 

Accidental dislocations are those in which the bones have suffered 
displacement in consequence of the application of a sudden force; and 
surgeons have divided these accidents into Complete and Partial, Simple, 
Compound and Complicated, Recent and Ancient, Primitive and Con- 
secutive. 

A complete dislocation is one in which no portions of the articular 
surfaces remain in contact. 

A partial dislocation is one in which the articular surfaces are not 
completely removed from each other. 

A simple dislocation is that form of the accident in which the bone has 
only slid from its articulation, and is accompanied with the least or only 
an average amount of injury to the soft parts or to the bones adjacent 
t<> the joint. 

A compound dislocation implies that the articulating surface of the 
bon»- has been thrust through the flesh and skin ; or that in some other 
way ;i wound lias been made which communicates with the joint. 

I implicated dislocation is a term employed by some writers to desig- 
nate a condition wholly differing from a compound dislocation, or, in some 
cases, ;i condition of extra complication. Thus, a simple dislocation may 
1m- complicated with ;i fracture, or with the laceration of an important 
bloodvessel, etc.; and a compound dislocation may be complicated in the 
same way. and with the addition, perhaps, of* extensive laceration and 
destruction of integument, muscles, nerves, etc. 

A recent luxation has taken place within a period of a few days, or, 

< r it most, of ;i few weeks ; and an ancient luxation has existed during a 

period. The exacl point of time at which a dislocation shall be 



630 GENERAL CONSIDERATIONS. 

called recent or ancient is not folly determined by surgeons, and the 
application of these terms is therefore always somewhat arbitrary. 

A primitive luxation is a luxation in which the bone remains nearly 
or precisely in the position into which it was at first thrown ; while a 
secondary or consecutive luxation is one in which the bone has subse- 
quently, in consequence of the action of the muscles, or from unsuccessful 
eiforts at reduction, or from some other cause, changed its position suffi- 
ciently to entitle the accident to a new designation. Thus a primitive 
dislocation upon the ischiatic notch may become a secondary dislocation 
upon the dorsum ilii, or the reverse. 

§ 2. General Predisposing Causes. 

Age. — According to Malgaigne, whose conclusions are based upon an 
analysis of six hundred and forty-three cases, dislocations are very rare 
in infancy, only one having occurred under five years ; but the frequency 
increases gradually up to the fifteenth year, from this period more rapidly 
up to the sixty-fifth year, and from this time onward again dislocations 
become more rare. He has mentioned none after the ninetieth year ; 
and the period of greatest frequency is between the thirtieth and sixty- 
fifth year. To this middle period belong four hundred and seven of the 
whole number. 

Kronlein 1 from an analysis of 400 cases has constructed the following 
table : 



Articulations. 1- 


-10 yrs. 


11-20. 


21-30. 


31-40. 


41-50. 


51-60. 


61-70. 


71-6 


Hip, 


4 






1 




2 


1 




Knee 




3 


"2 


1 




1 






Foot,' ...... 








1 






1 




Metatarsophalangeal, . 




1 








"i 






Shoulder, 




2 


55 


45 


48 


36 


19 


2 


Elbow 


31 


49 


15 


5 


4 


Q 


1 


1 


Hand, 






1 












M etacarpo-phalangeal , 


6 


*8 


4 


8 


1 








Interphalangeal, . . 


1 




5 


1 


1 








Sterno-clavicular, . 


1 


3 


2 












Acromio-clavicular, 




1 




2 


4 


3 


1 




r jaw, . 




2 


4 


1 


2 


1 









1 

















44 69 88 65 60 48 23 3 

The inference from these analyses may be thus briefly stated : age, as 
a general predisposing cause, is most active in middle life, and least 
active in advanced and in early life. 

It is proper, however, to observe that while such statistics may be 
relied upon as indicating the relative frequency of these accidents at dif- 
ferent periods of life, they cannot be regarded as determining absolutely 
the value of age alone as a predisposing cause, since the direct or exciting 
causes may be more active at one period than another, and in some 
measure these latter causes may be, and doubtless are, responsible for 
sue) i results. 

1 Kronlein, Luxation en, Deustche Chir. Von. Billroth u. Luecke, 1882 3 p. 5. 



DIRECT OR EXCITING CAUSES. 631 

Constitution and Condition of the Muscles and Ligaments. — It may 
be stated as a general fact that persons of feeble constitutions, and whose 
muscular systems are much weakened, suffer dislocation from slighter 
causes than those who are in health, and whose muscular systems are 
firm and vigorous : and that a relaxation of the ligaments which sur- 
round a joint, however this may have been occasioned, predisposes to 
dislocation. Thus, a paralyzed and atrophied limb is predisposed to 
luxation: a joint in which the capsule has become stretched by effusions, 
or by violent extension, or weakened by laceration from a previous dis- 
location, or by ulceration, or if in any other way the articulation is de- 
prived of these natural protections, we need scarcely say, it is thereby 
rendered more liable to luxation. 

Ball-and-socket joints, other things being equal, are more liable to 
displacement than ginglymoid ; but then much more depends upon the 
relative exposure of the joint than upon its anatomical structure, so that 
the elbow is much more frequently dislocated than the hip ; the shoulder- 
joint, however, being, from its position and extent of motion, peculiarly 
exposed, and being also a ball-and-socket joint, is, of all others, most 
liable to dislocation. 

§ 3. Direct or Exciting Causes. 

These may be classed under two general heads, namely, external 
violence and muscular contraction. The action of certain ligaments in 
determining the direction of some dislocations, is also a direct cause, but 
only subsidiary to the other causes named. 

External violence operates either directly or indirectly. When a 
person falls upon the knee and dislocates the head of the femur, the 
force is said to have acted indirectly, and this is by far the most frequent 
mode of dislocation ; but when the blow is received upon the upper end 
of the humerus, and its head is sent into the axilla, it is said to have 
been dislocated by direct violence. 

Muscular action produces a dislocation slowly, as in some cases of 
chronic rheumatism, and then it is termed a spontaneous or pathologic 
dislocation : or suddenly, as in the violent spasmodic contractions which 
accompany convulsions ; or sometimes by the mere voluntary effort of 
the muscles : and both of these latter are true accidental luxations. 

It is very probable that external force can seldom be regarded as the 
sole cause of a dislocation, but that, in a large majority of cases, mus- 
cular action consenting with the shock, performs an important role in the 
history of the accident. The limb, being driven obliquely across its 
by the external violence, is seized by the stretched and excited 
muscle- with such vigor as to contribute not a little to the unfortunate 
result. Thus it will be found thai the same force which is adequate to 
the production of a dislocation in the living and healthy subject is wholly 
insufficient to accomplish the same in the dead ; and a man who is fully 
intoxicated seldom suffers a dislocation. 



( . E N R R AL CONSIDE R AT10 N S . 



§ 4. General Symptoms. 

As fractures are characterized by preternatural mobility and crepitus, 
to which may be generally added the circumstance that when reduced 
the fragments will not remain in place without external support; so, on 
the other hand, dislocations are characterized by preternatural rigidity, 
an absence of crepitus, and by the fact that when reduced the bone does 
not generally require support to maintain it in position. 

These three are the usual, and they may be termed the common, signs 
of distinction between fractures and dislocations, but no one of them can 
be alone depended upon as positively diagnostic. Generally, when a 
bone has been dislocated, we shall find the limb in a certain position, 
which is uniform for all dislocations of the same character, and almost 
immovably fixed ; but when the ligaments and muscles about the joint 
have been extensively torn, or the whole body is still suffering under the 
shock, or in any other circumstances where the power of the muscles is 
weakened, this rigidity may give place to extreme mobility. 

True crepitus does not exist without fracture, but it is not always 
present in fractures ; and there is often a sensation produced in the rub- 
bing and chafing of dislocated bones which very much resembles certain 
kinds of crepitus, and by the inexperienced has been often mistaken for 
it. I allude to the subdued rasping sound or sensation which is found 
generally on the second or third day, and sometimes earlier, and which 
is the result of fibrinous effusions, or, perhaps, in some instances, of the 
mere rubbing of firmly compressed ligamentous and cartilaginous surfaces 
upon each other. The crepitus of a recent fracture can be scarcely con- 
founded with this obscure sensation, unless it is in some cases of incom- 
plete fracture, or of a fracture situated remote from the surface, as in 
the case of the hip ; but a fracture which is a few days old, whose sur- 
face has become softened by inflammation and more or less covered with 
lymph, when the rigidity is great, may sometimes deceive the most 
experienced surgeon ; so exactly will it be found to imitate the sensations 
produced by the chafing of an inflamed joint, or of closely approximated 
fibrous surfaces. 

I have said that a true crepitus does not exist without a fracture ; but 
then a very minute fracture, such as the detachment of a scale of bone 
by the tearing away of a tendon or of a ligament, may produce crepitus; 
or even the separation of a piece of cartilage may sufficiently expose the 
bone to determine the presence of this phenomenon. These are, how- 
ever, no longer examples of simple dislocation. 

Xoi- are the two inverse propositions, in relation to the retention of 
the hones in place, invariable in their application. A broken bone, well 
reduced, does not always manifest a tendency to displacement; nor does 
a dislocated limb, when restored to its socket, in all cases maintain its 
position without support. 

The other general signs of dislocation are pain, swelling, and discolor- 
ation. The pain is generally more intense in dislocations than in frac- 
tures, the expanded end of the bone resting often upon one or more 
large nerves, which usually, with the arteries, approach very near the 



PATHOLOGY. 633 

joints : this pressure being also greatly increased by the extreme tension 
of the muscles. Not unfrequently numbness and temporary paralysis of 
the whole limb are the consequences. In other cases the pain is due 
solely to the pressure upon the muscles or to the tension of the muscles, 
or, perhaps, to the tension of the untorn ligaments and capsule. 

Generally the limb is shortened, but in a few cases it is found slightly 
lengthened, while the natural axis of the bone with its socket is always 
changed. If examined early, and before the supervention of swelling, 
the joint end of the displaced bone may be felt in its unnatural position, 
and a corresponding depression may be discovered in the situation of the 
articulation, especially if the bones are superficial. 

§ 5. Pathology. 

The dissection of recent dislocations produced by external violence, 
shows the capsular ligaments more or less torn, and also a rupture of 
some of the lateral and other short ligaments, with a complete rupture in 
most cases of some of the tendons which immediately surround the joint, 
or of those which are attached to the capsule : the muscles, nerves, arte- 
ries, etc., through which the bone in its passage has passed, or upon 
which it is found resting, being also contused, stretched, or torn asunder. 

This description, however, does not apply to dislocations produced by 
muscular action alone, in a majority of which cases the capsule is only 
stretched, and not torn, and no lesions of other structures are necessarily 
present. 

If the dislocation remains unreduced, the margins of the old socket, in 
the cases of enarthrodial articulations, become gradually depressed, while 
the concavity of the socket is filling in with a fibrous or bony tissue, until 
at length the whole of this portion of the joint apparatus is nearly or 
entirely obliterated. This process is generally very slow, and may not 
be consummated until after the lapse of many years. 

At the same time, but with much greater rapidity, the head of the bone 
in its new position, and the soft or hard parts upon which it rests, are 
undergoing certain changes to adapt them to their new relations, and cal- 
culated in some measure to restore the limb to its normal functions. If 
the head of the bone rests upon muscle, the cellular and fibrous tissues 
which enter into the composition of the muscle become condensed and 
thickened, forming a shallow or elongated cup, whose margins are 
attached to the neck, or shaft of the bone, and whose walls are lubri- 
cated with synovia. If it rests upon bone, by a process of interstitial 
absorption a true socket is formed, sometimes deep and sometimes shal- 
low, whose edges, receiving additional ossific depositions, become lifted 
so as to form a rim. At the same time the head of the bone is under- 
going corresponding changes, to adapt itself to the newly formed socket ; 
it i- flattened or otherwise changed in form, and in the progress of this 
change its natural secreting and cartilaginous surfaces are gradually 
removed, a porcelaneous deposit taking it- place. The same kind of 
hard, polished, ivory-like deposit is found also in those portions of tin; 
new socket which have been especially exposed t<» pressure and friction. 



634 GENERAL CONSIDERATIONS. 

Instead of the eburnation, an imperfect fibro-serous surface or synovial 
capsule may be formed. 

I have in my cabinet an example of ancient luxation of the hip-joint in 
which the head of the femur, having rested upon the dorsum ilii, has 
formed a nearly flat hut smooth surface — a kind of elevated plateau; in 
other cases I have scon the margins of the new socket so elevated as to 
rest against the neck of the femur, and completely lock it in. 

Coincident with these changes, and in consequence partly of the disuse 
of the limb, the muscle, and even the bones sometimes suffer a gradual 
atrophy. In some measure these alterations may be due also to the pres- 
sure of the dislocated bone upon arterial and nervous trunks, by which 
their functions become partially or completely annihilated, and their 
structure even may be wholly obliterated. In consequence also of the 
inflammation which immediately results, we ought not to omit to notice 
that the trunk of a large artery sometimes becomes firmly adherent to 
the capsule or periosteum of a displaced bone, and its reduction is 
attended with imminent danger of laceration and of a fatal haemorrhage. 
Numerous instances of this grave accident, especially in attempts to 
reduce old dislocations of the shoulder-joint, are upon record. 



§ 6. General Prognosis. 

We shall study the prognosis of these accidents to better advantage 
when we come to speak of the individual bones and their various forms 
of dislocation ; but it is proper to state in this place, generally, that very 
few joints, having been once completely displaced from their sockets by 
external violence, are ever so completely restored as not to leave some 
traces of the accident, for many years, if not for the whole of the subse- 
quent life of the patient, either in the partial limitation of their motions, 
or in the diminished size and power of the muscles of the limbs, or in the 
presence of an occasional arthritic pain: the degree and permanence of 
these sequences depending upon the joint which is the subject of the dis- 
placement, the extent of the original injury, the length of time it has re- 
mained unreduced, the means employed in its reduction, the health and 
condition of the patient, with so many other contingent circumstances as 
to preclude the idea of a complete specification. 

If the hone is not reduced, a permanent maiming is inevitable; but it 
is surprising how much, time and the intelligent processes of nature can 
eventually accomplish toward a restoration of the natural functions, espe- 
cially when aided by a good constitution and judicious treatment. If 
the symmetry of form and grace of motion are never replaced, the value 
of the limb, for all the practical purposes of life, is not unfrequently 
completely reestablished. 



?; 7. General Treatment. 

The first indication of treatment is to reduce the bone. Whatever de- 
lay- may he proper or justifiable in certain cases of fracture, such delays 
are never to he argued in cases of dislocation. The sooner the reduction 



GENERAL TREATMENT. 635 

is accomplished the better. For this purpose we resort at once to such 
manipulations or mechanical contrivances as the nature of the case de- 
mands : and if these fail, or if at the first they are deemed insufficient, 
we invoke the aid of constitutional means, or such as are calculated to 
diminish the power and antagonism of the muscles. 

Many dislocations may be reduced promptly by manipulation alone; 
which mode is always to be preferred when it will prove sufficient, for 
the reasons that it is generally the least painful to the patient, and the 
least apt to inflict additional injury upon the muscles and ligaments. 

A person wholly unacquainted with anatomy or surgery may occasion- 
ally succeed in reducing a dislocated limb ; indeed it frequently happens 
that the patient himself, by mere accident in getting up or in lying down, 
accomplishes the reduction; and even in a very large majority of cases, 
force and perseverance will finally succeed by whomsoever they may be 
employed: but the observing student of surgery will soon discover the 
difference between accident and brute force on the one hand, and intelli- 
gent manipulation on the other. The charlatan bone-setter does not 
often allow himself to fail, unless the courage of his patient gives out, or 
he ignorantly supposes the reduction to be effected when it is not ; but 
his success, achieved through great and unnecessary suffering, is often 
obtained, also, at the expense of the limb; while the surgeon, whose 
knowledge of anatomy enables him to understand in what direction the 
muscles are offering resistance, and through what ligaments the head of 
the bone must be guided, lifts the limb gently in his hands, and the bone 
seeks its socket promptly and without disturbance, as if it needed only 
the opportunity that it might demonstrate its willingness to return. 

We must understand not only what muscles and ligaments antagonize 
the reduction, if we would be most successful, but also what muscles, by 
being provoked to contraction, will themselves aid in the reduction. In 
short, to become expert bone-setters in the department of dislocations, 
one must possess a complete knowledge of the physiognomy or the ex- 
ternal aspect of joints, acquired only by repeated and careful examina- 
tions, he must be familiar with the anatomy and functions of the muscles, 
he must understand thoroughly the ligaments, he must have experience, 
tact, and fertility of resource. 

Without these qualifications a man will do better never to undertake 
to treat dislocations, since he is constantly liable to mistake fractures for 
dislocations, and dislocations for fractures; he will submit a sprained 
wrist to violent extension, under the conviction that the joint is dis- 
placed : he will mistake natural projections for deformities, and fail to 
i ize the real deformity when it actually exists : he will leave bones 
unreduced, rally believing that they are reduced; and he will, all in all, 
within a few years, accomplish vastly more evil than he can ever do good. 
Let a man practise any other branch of surgery if he will, without ex- 
perience or scientific knowledge, but he must not attempt to reduce 
dislocated bones. The most learned and the most skilful we shall find 
falling into error, embarrassed by the uncertainty of the diagnosis, or 
successfully resisted by the power of the opposing agents. What, then. 
can be expected of those who are both ignorant and inexperienced hut 
failures and disasl 



636 



GENERAL CONSIDERATIONS. 



Fig. 261. 



A- a means of disarming the muscles, or of placing them oft* their 
guard, we often practise successfully the diversion of the mind of the 
patient. At the very moment that the limb is moved or extension is 
made, a question is addressed to him, or he may be suddenly surprised 
by some unexpected intelligence. 

Extension and counter-extension, made with our own hands or with 
tlic hands of assistants, constitute the second resort where manipulation 
alone has failed. The surgeon, seizing upon the limb firmly with his 
hands, makes the extension, while the assist- 
ants make the counter-extension; or, instead 
of grasping the limb directly, the operator 
may use for this purpose circular and longitu- 
dinal bandages, or the bandage or handker- 
chief tied in the form of the clove-hitch. Ex- 
tension is thus applied in connection with 
manipulation, aided, perhaps, by direct pres- 
sure upon the head of the displaced bone. 
Failing in this, we employ some one of the 
various mechanical contrivances which, while 
they are capable of exerting much more power, 
possess also the important advantage of ope- 
rating gradually and steadily, by which mode 
the resistance of the muscles is always more 
speedily and more completely overcome. 

For this purpose, Legros and Anger 1 have 
proposed the use of India-rubber tubes, to the 
number of five or six, extended gradually and 
successively to a proper tension, and main- 
tained in this degree of tension for twenty or 
thirty minutes ; and others have advised the 
use of the pulley and weights, the latter of 
which methods I have often employed myself; but surgeons employ 
generally, in the case of the large limbs, the compound pulleys, or the 
simple rope windlass, which latter is thus described by Dr. Gilbert, of 
Philadelphia : "Place the patient, and adjust the extending and counter- 
extending bands as for pulleys ; then procure an ordinary bed-cord or a 
wash-line, tie the ends together, and again double it upon itself, pass it 
through the extending tapes or towels, doubling the whole once more, 
and fasten the distal end, consisting of four loops of rope, to a window- 
sill, door-sill, or staple, so that the cords are drawn moderately tight; 
finally, pass a stick through the centre of the double rope, then by re- 
volving the stick as an axis or double lever, the power is produced 
precisely as it should be in such cases, viz., slowly, steadily, and con- 
tinuous] v. " 

Jarvis's adjuster, although very complex, possesses some advantages 
over the pulleys, which may. perhaps, entitle it to the preference in a 
few cases. (See Dislocations of* the Thigh.) 

Sedillot, 2 recognizing the danger of over-extension in the employment 




Clove-hitch. (From Erichsen.) 



Legros and A.nger, Arch. Gen.de Med., 1867. 

SeVlillot et Gross, Art. Luxations, Die. Encyc. Sci. Med., Ser. 2d, t. ! 



. 295 



DISLOCATIONS OF THE LOWER J AAV. 



637 



of mechanical apparatus, and especially in the employment of the 
pulleys, conceived the idea of attaching to the latter a dynamometer, by 
which the exact amount of force applied could be determined. It is not, 
however, by any means certain that the dangers would be lessened by 
this means, since the amount of force which can safely be employed is 
seldom the same in any two cases which may be presented ; but, de- 
pending, as it must, upon the limb to which the traction is applied, its 
muscular power or resistance, the age, sex, and general condition of the 

Fig. 262. 





Compound pulleys, and ring to which one end of the pulley-rope is fastened. 

patient, it is apparent that the limits of safety must be determined by 
the constant and careful observation of the limb while the extension is 
being applied, and, in short, by the judgment of the surgeon rather than 
by any fixed dynamic rule. 

Among the constitutional means, ether and chloroform occupy the first 
rank ; indeed, they are, at the present day, almost the only means of this 
class to which surgeons resort, and their value in this point of view can 
scarcely be over-estimated. Only when some unusual circumstance or 
condition of the patient forbade the use of an anaesthetic, would the 
Burgeon return to the ancient practice of bleeding ad deliquium, of 
prostrating the system with antimony, or to the use of those vastly less 
efficient agents, opium and the warm bath. 



CHAPTER II. 

DISLOCATIONS OF THE LOWER JAW (TEMPORO-M AXILLARY). 

There are two principal forms of this dislocation, namely, the double 
or bilateral dislocation, and the single or unilateral; in both of which 
the direction of the displacement is forwards. To these there may be 
added a- having been occasionally observed an outward displacement 
accompanied with a fracture, and occasionally a backward dislocation, 
with fracture of the meatus auditorius externus. 



638 DISLOCATIONS OF THE LOWER JAW 



§ 1. Double or Bilateral Dislocation Forwards. 

This form of dislocation of the lower jaw is much the most frequent, 
being met with in about two out of every three cases. It appears also 
to occur oftener in women than in men. and usually between the twentieth 
and thirtieth year of life. In infancy and extreme old age it is exceed- 
ingly rare : yet Sir Astley Cooper mentions a case in which, "two boys" 
being at play, one had an apple thrust into his mouth, producing a double 
dislocation ; and Nelaton saw the same accident in an old man of seventy- 
two years, who was toothless. 

This comparative immunity in youth and old age has been ascribed to 
certain peculiarities in the form of the jaw at these periods of life. Ne- 
laton attributes its more frequent occurrence in middle life to the great 
length and strong anterior inclination of the coronoid process. 

In a majority of cases the direct or immediate cause has seemed to 
be muscular action alone. Malgaigne found this cause to prevail in 
twenty-five out of forty cases ; and of the twenty-five cases fifteen were 
occasioned by gaping, five by convulsions, four by vomiting, and one by 
rage. Dr. Physick, of Philadelphia, found both condyles dislocated in 
a woman in consequence of the violent gesticulation of her jaw while 
scolding her husband. But in a more remarkable case still, this surgeon 
found the jaw dislocated after recovery from a profuse salivation, and of 
the cause of which, or the time of its occurrence, the patient, a young 
girl, could give no account. Dr. Physick made several ineffectual at- 
tempts at reduction, and only succeeded at last after he had made her 
completely intoxicated with ardent spirits. 1 

Dr. E. Andrews, of Michigan, found both condyles dislocated by a 
lobelia emetic. The patient had often taken these emetics before, and 
had frequently experienced a sensation " of catching " at the joint, but 
the jaw had always until this time resumed its position spontaneously. 2 

Dr. A. H. Steen, of Minnesota, met with a bilateral dislocation caused 
also by vomiting. 3 Dr. Edwin Morris 4 has seen the same occur during 
sleep with a young lady who from infancy had been accustomed to suck 
her tongue. 

Among the causes from outward violence, the introduction of some 
foreign body into the mouth, and the extraction of teeth, occupy the 
most important place. In fifteen cases seven were from the former and 
six from the latter cause. 

My former pupil, Dr. A. W. Gilbert, has related a case which came 
under his own observation, produced by a similar cause. During his 
apprenticeship with Dr. Parsons, a dentist, he was requested to insert a 
set of teeth for a young man residing in Cattaraugus Co., N. Y., and 
while opening his mouth to take an impression of his gums, he dislocated 
" both condyles forwards, under the zygomatic arches ;" but so perfectly 
were the muscles relaxed, that he immediately reduced them, without the 

1 Physick, Dorsey's Elements of Surgery, vol. i. p. 202. Philadelphia, 1813. 

2 Andrews, Peninsular Journ. fifed., vol. iii. p. 101, 1855. 

3 Steen, Virginia Med. Monthly, June, 1878, p. 220. 
* Morris, Brit. Med. Journ., Aug. 81, 1872. 



DOUBLE OR BILATERAL DISLOCATION. 639 

least difficulty, by placing his thumbs as far back as possible upon the 
molar teeth, depressing the back part of the jaw, and at the same moment 
elevating the chin. 1 

Prof. James Webster, of Rochester, N. Y., dislocated the jaw of a 
lady while attempting to pry out a root of one of the molars. 

Pathology. — In order that we may better understand the pathology 
of this accident, it will be proper to say a few words in relation to the 
anatomy of the temporo-maxillary articulation and the other parts con- 
cerned in the dislocation now under consideration. 

The articulation is formed by the condyloid process of the inferior 
maxilla and the glenoid fossa of the temporal bone, in front of which 
fossa, and at the root of the zygomatic arch, is a slight elevation, called 
the articular eminence. Between the joint surfaces, both of which are 
covered with cartilage of incrustation, is placed an interarticular carti- 
lage, which divides the joint into two cavities, one corresponding to the 
condyle of the inferior maxilla, and the other to the glenoid fossa, each 
of which is furnished with a distinct synovial membrane. 

Properly there is but one ligament — namely, the external lateral — 
which passes from the outer surface of the articular eminence to the cor- 
responding surface of the neck of the condyle. What is called the in- 
ternal lateral ligament arises from the apex of the spinous process of the 
sphenoid bone, and is inserted into the margin of the dental foramen, and 
has therefore no immediate connection with the articulation, although it 
tends to strengthen the joint. The same is true of the stylo-maxillary 
ligaments. 

The lower jaw is drawn upwards, or closed upon the upper jaw, by the 
action of the temporal, masseter, and internal pterygoid muscles ; it is 
drawn downwards by the action of the digastricus, mylo-hyoideus, and 
genio-hyoglossus muscles ; forwards by a few fibres of the masseter and 
by the external pterygoid muscles ; and laterally by the alternate action 
of the external and internal pterygoid muscles. 

When the mouth is open to its utmost extent, the maxillary condyle 
rises upon the articular eminence until it rests upon its very summit. 
Indeed, it is probable that in most persons it advances rather in front of 
the centre of the eminence ; so that in order to become actually dislo- 
cated it only needs that the capsule shall be somewhat relaxed, or that 
it Bhall actually give way in front, when the condyles slide forwards and 
occupy a position directly in front instead of behind this eminence. 

It is easy to comprehend how the combined action of the two external 
pterygoid muscles, with a portion of the fibres of the masseter, may 
alone produce the dislocation when the mouth is wide open, and espe- 
cially when, in consequence of a slight blow upon the chin, the anterior 
portion of the capsule becomes lacerated; for it must be noticed that 
the ascending ramus, with its prolonged condyloid process, constitutes a 
lever of the first kind, in which the temporal muscle, attached to the 
coronoid process, the masseter, and even the mastoid process, constitute 
the fulcrum, the anterior portion of the capsule, the weight, and the 
force acting against the front of the chin, the power. 

1 Gilbert, Thesis on Dislocation of the Inf. Max. University of Buffalo, 1858. 



640 



DISLOCATIONS OF THE LOWER JAW. 



Fig. 263. 




Double dislocation of the inferior maxilla, 
forwards. 



In this position of the condyle, drawn upwards and forwards by the 
action of the pterygoid and temporal muscles, the chin descends toward 

the neck, and the coronoid pro- 
cess rests against the back of the 
superior maxilla, or against the 
malar bone at the point of its 
junction with the upper maxil- 
lary. The temporal, masseter, 
and internal pterygoid muscles 
are very much upon the stretch, 
if not more or less lacerated. 

In addition to the influence of 
muscular action and the hooking 
of the condyle upon the malar 
and maxillary bones in maintain- 
ing the dislocation after it has 
once taken place, and in offering 
an obstacle to its reduction, there 
is to be considered the occasional 
displacement of the interarticular cartilages, as demonstrated by Demar- 
quay, 1 Mathieu, 2 and Perier. 3 

Symptoms. — The mouth is widely open and the jaw nearly immovable. 
It has been noticed generally that, by pressure, the chin may be slightly 
depressed, but that, owing probably to the pressure of the coronoid process 
against the body of the upper maxilla, or against the malar bone, it is 
generally impossible to elevate the jaw in any degree whatever. 

The jaw is also slightly advanced ; a depression, covering a consider- 
able space, exists between the auditory canal and the posterior margin 
of the condyle. A slight fulness is observed in the temporal fossa, and 
also upon the side of the cheek in the region of the masseter muscle. 

Ordinarily the patient suffers considerable pain, but not always, from 
the pressure of the condyles upon the branches of the temporal nerves. 
There is a constant flowing of the saliva from the mouth ; the patient 
is unable to articulate, and even deglutition is performed with great 
difficulty. 

Prognosis. — When the dislocation remains unreduced, the lower jaw 
gradually approximates the upper, and its anterior projection sensibly 
diminishes, the saliva ceases to dribble from the mouth, deglutition and 
speech are restored, mastication is performed with considerable ease, and, 
in short, the patient comes at length to experience no great inconvenience 
from the displacement. 

Robert Smith relates the case of a woman whose lower jaw was dis- 
located during an epileptic convulsion. She was at the time in one of 
the metropolitan hospitals, but the accident was not noticed by the sur- 
geons, and it remained ever afterwards unreduced. At the end of a year 
she could close the lips perfectly, but was able to open the mouth only 
to a limited extent : the teeth of the lower jaw remained advanced, the 



Poinsot, op. cit, p. 743. 2 Ibid. 

3 Perier, Bull. ><><■. Chir. de Paris, 1878, p. 223. 



DOUBLE OR BILATERAL DISLOCATION. 



641 



Fig. 264. 



involuntary flow of saliva had ceased, and the faculty of speech had been 
regained. 1 In Professor Webster's case, to which I have before referred, 
although the jaw was immediately and easily reduced, after the lapse 
of several years, when I saw the lady, she still complained that it hurt 
her whenever she ate, and that she often felt the condyles slip in their 
sockets. 

Reduction was accomplished by Physick in the case already related, 
after the lapse of several weeks ; Sir Astley Cooper reduced a double 
dislocation after a month and five days, which had been overlooked by 
the surgeon in attendance ; 2 and Donovan succeeded after ninety-five 
days. 3 

In two cases treated by Michon and G-osselin the reduction was effected 
at one hundred and thirty days. 4 

Treatment. — Reduction may generally be accomplished with ease in 
cases of recent dislocation, in the following manner : The patient being- 
seated upon the floor with his head 
between the knees of the operator, a 
couple of pieces of cork, gutta percha, 
or pine wood are placed as far back 
between the molars as possible, when 
the surgeon seizing upon the chin 
draws it steadily upwards, taking care 
not to draw it forwards at the same 
time, since by this movement he would 
resist the action of the muscles which 
naturally tend to restore it to place 
whenever the condyloid processes are 
lifted sufficiently from the zygomatic 
Many surgeons prefer to sit 
or stand in front of the patient, and 
depress the condyles by means of the 
thumbs placed inside of the mouth 
and upon the tops of the molars. If 
the thumbs are used in this way, it 
would be well to protect them with a 
piece of leather, or to slip them off 
from the teeth suddenly when the con- 
dyles fire gliding into their places, as 
the muscles >ometimes close the mouth with sufficient violence to bruise 
rely anything which might at that moment be interposed between 
the teeth. 

The method practised by Ravaton, of simply lifting the chin gradu- 
ally and forcibly toward the upper jaw, was essentially the same, but 
far less efficient ; for, although he placed nothing between the molars 
to serve as a fulcrum, the backmost teeth themselves must in. some 




Double dislocation of the inferior 
maxilla, forwards. 



1 Robert Smith, on Fractures and Dislocations. Dublin, 1854, p. 288. 

2 Sir Astley Cooper, on Di.~l"<;. and Frac, Ainor. ed., \>. 316. 

8 Donovan' Amor. Journ. Med. Sci., Oct. 1842, p. 470; from Dublin, Med. Press, 

L842. 
4 Poinsot, op. cit., p. 744. 

41 



042 DISLOCATIONS OF THE LOWER JAW. 

degree perform this service whenever, the lower jaw being dislocated 
and drawn upwards, the chin is forcibly approximated toward the upper. 

In other cases it has been found necessary first to disengage the coro- 
noid process, by depressing the chin gently, and then pressing backwards 
in the direction of the articulation; a method which would certainly 
deserve a trial in case of the failure of that first described. This was 
the method practised by Hippocrates. Lateral pressure made directly 
upon the condyle may facilitate the reduction. 

A more effectual expedient, however, consists in reducing one side at 
a time: taking good care always that the side first reduced is not redislo- 
cated while the attempt is being made to reduce the other, a thing which 
happened in one of the cases treated by Sir Astley Cooper, and has 
happened many times in the practice of other surgeons. 

Finally, if all other expedients fail, we ought not to hesitate to resort 
to anaesthetics, nor indeed could any objection exist to their employment 
at any period of the treatment, were it not that in a large majority of 
cases the reduction is effected so easily and promptly as to render their 
employment wholly unnecessary. 

After the reduction is accomplished, it will be a matter of wise precau- 
tion to sustain the jaw by a double-headed bandage passed under the 
chin, and secured upon the top of the head; so as to prevent the mouth 
from being accidentally opened too far, especially during sleep, since 
experience has shown that a tendency to a reproduction of the disloca- 
tion remains for some time. It will be prudent to continue these measures 
of protection for at least one w 7 eek ; after which the danger of anchylosis 
should be borne in mind, and the extent of passive motion should be 
gradually and cautiously increased. In illustration of this tendency to 
redislocation, Malgaigne refers to the case mentioned by Putegnat of a 
woman whose jaw for many years became dislocated at least once a month ; 
but she was always able to reduce it herself. 

§ 2. Single or Unilateral Dislocations Forwards. 

The causes of this accident are in general the same as those which 
produce double dislocations, and it occurs most often in middle life. 
Tartra has seen one exceptional example in a child only fifteen months 
old, and Levison saw a case in an old man who had lost all his teeth. 1 

Symptoms. — The mouth is open, but not so widely as in double dislo- 
cation : the jaw is nearly immovable; the teeth are advanced; the con- 
dyloid process can be felt in front of the articular eminence, leaving a 
depression in its natural situation, and the coronoid process is more promi- 
nent than in the bilateral dislocation. 

It will be remembered that we have already pointed out an important 
diagnostic mark between a fracture of the neck of the condyloid process 
and a dislocation of one condyle. In the latter the chin inclines to the 
opposite side, while in the former it falls toward the side upon w 7 hich the 
accident has occurred. According to Hey, this lateral deviation of the 

1 Levison, Boston Med. and Surg. Journ., vol. xxxiv., 1846, p. 388, from London 
Lancet. 



DISLOCATIONS BACKWARDS, WITH FRACTURE. 643 

chin is not always present in dislocations ; and Robert Smith mentions 
one case in which the surgeon was misled by this circumstance so far as 
To attempt a reduction upon the left side when the dislocation was upon 
the right. 

Treatment. — The same rules of treatment which I have established 
for dislocations of both condyles will be applicable to the single disloca- 
tions, with only such modifications as will be naturally suggested to the 
surgeon. 

In the case mentioned by Levison, the dislocation was constantly re- 
curring upon the left side; and it was especially liable to happen when 
just awakening from sleep. " He would then pull his jaw, press it back- 
wards, when, after about half an- hour's work, bang it seemed to go, and 
all was -right again." This old gentleman was finally relieved of these 
annoyances by a band fastened under the chin. In such a case, an ap- 
paratus constructed after the same plan as my lower jaw apparatus might 
perhaps serve a useful purpose. 

§ 3. Dislocations Outwards, with Fracture. 

Robert 1 was the first to observe this fact. The dislocation (left side) 
occurred in a man whose face had been traversed by the wheel of a cart, 
and was accompanied with a fracture in front of the ascending branch of 
the jaw on the right side. The dislocated condyle projected outwards 
and could be distinctly felt and seen under the skin. The chin was 
inclined to the same side. 

In 1879 Dr. Xeis 2 observed a second example of tjiis dislocation, which 
he describes as " outwards and upwards into the temporal cavity," unac- 
companied with fracture of the jaw. The subject was a young man 
whose chin and occiput were pressed between two boats. Dr. Neis sup- 
posed a fracture of the glenoid cavity, but he was not able to establish it. 

§ 4. Dislocations Backwards, with Fracture, 

Baudrimont, 3 of Bordeaux, relates the following case : " September 
25. 1879, Marianno M., a cartman, aged 63, who had lost all the teeth 
of the upper jaw, and a number of the molars of the lower, fell violently 
on his chin, experiencing at the moment a violent pain in both ears, and 
when lie arose he found himself unable to move his jaw. There was a 
wound on the chin, absolute deafness existed, accompanied with an otor- 
rhcea which continued until the following day. He was on the same day 
admitted to the Hospital of St. Andre, of Bordeaux. His mouth was half 
open, the chiu receded behind the upper jaw, as determined by the posi- 
tion of the incisors, fifteen millimetres. The lips could be closed, but 
the jaws could not. The backward displacement of the lower jaw caused 
a flattening of the cheeks, and gave to the mouth a peculiar grimace. The 
posterior portion of the jaw touched the sterno-mastoid muscle. The 

1 Robert, Journ de Chir., 1844, p. 265. 

2 New, Thesede Paris, 1879, No. 252. (Poinsot.) 

3 Baudrimont. Journ. de M&L de Bordeaux, 1882, 13, 20, 27 aout. (Poinsot.) 



644 DISLOCATIONS OF THE LOWER JAW. 

condyle was absent from its socket. Both auditory canals were closed 
by hard anteroinferior projections, which obeyed the slight movements 
which al<»nc could be given to the jaw. The reduction was immediately 
attempted.'' 

M. Baudrimont describes his method of procedure as follows: "The 
patient is seated on a chair, his head slightly thrown back and held by 
an assistant. Both thumbs are with difficulty introduced on both sides 
between the jaws, which can only be done by exaggerating the backward 
rocking movement of the jaw ; the thumbs press, by their palmar sur- 
faces, on the lower molars. The other fingers brought under the chin, 
seize the body of the jaw, in a firm grip, on both sides. I press pro- 
gressively and very energetically downwards at first, then downwards 
and forwards. A sudden disengagement of the right condyle, which re- 
gain- its place, is at first obtained with comparative ease. The dislocation 
is now single. The chin is deviated to the left. The same attempt is 
then made on the left side, but I then experience far more difficulty : 
a considerable effort proves insufficient ; but with the help of the fingers 
pressing upon the condyle which is disengaged, the jaw rotates on itself 
and seems to make the hand which accompanies it describe a large circle, 
and the condyle resumes its articulation with a noise heard at a distance. 
The last phase of the reduction seems very painful, and as soon as the 
condyle leaves the ear the blood begins to now from the left side. The 
movements of the jaw are reestablished, and are not very painful. Deaf- 
ness partially disappears. 

" Examination of the ears shows that the membrane of the tympanum 
is torn on the right side, and there are in both auditory canals wounds 
of the integuments in which the probe detected bony splinters. Different 
local accidents ensue ; sero-sanguinolent, serous, and sero-purulent dis- 
charges take place : also a swelling of the articular regions, and, later on, 
Buppuration. The patient left the hospital in a good condition. Three 
months after there still remained some swelling, articular stiffness, and a 
certain degree of deafness." 

It would seem, according to the researches of Baudrimont, that this 
accident had been described by Lanfranc, Guy de Chauliac, and Jean de 
Vigo, but that not until recently had any well-authenticated examples 
been published. Indeed, Baudrimont alone has recorded an example of 
bilateral dislocation backwards. In a case reported by Croker-King the 
dislocation was unilateral, and was reduced by a method similar to that 
employed by Baudrimont, but it was not followed by any accidents; 
while Lefevre mentions a unilateral dislocation backwards which resulted 
in a cerebral abscess and death about five months after the injury was 
received. The dislocation was not recognized until the autopsy was 
made 

In all of these examples the condyle, which rests with its centre over 
the point where the bony portion of the external auditory canal joins the 
cartilaginous portion, being thrust backwards has broken the margin of 
the bony portion and displaced or torn the cartilaginous portion, but 
without rupture of tin- ligaments. 



CONDITIONS OF THE JAVT SIMULATING DISLOCATIONS. 645 



§ 5. Conditions of the Jaw simulating 1 Dislocations. 

There is a condition of the temporo-maxillary articulation called by 
Sir Astley Cooper "subluxation of the jaw," in which it is assumed that 
the condyles slip before the anterior margins of the interarticular carti- 
lages, and thus for the time render the jaw immovable. No positive evi- 
dence, however, has ever been presented, either by Sir Astley or others, 
that any such derangement of the joint apparatus does actually take place, 
the opinion being based, not upon dissections, but only upon the symp- 
toms which are known to accompany the accident. It is quite probable 
that this explanation of the phenomena in question is the true one, yet it 
is not impossible that, in some rare cases, it has no relation whatever to 
the interarticular cartilages, but that it indicates a true subluxation of the 
inferior maxilla upon the zygomatic eminences. 

It occurs mostly in young people, and in those of a feeble or scrofu- 
lous diathesis. Relaxation of the capsule, ligaments, and muscles about 
the joint may, therefore, be regarded as the principal predisposing cause. 
The exciting causes are generally yawning, or biting upon some very 
hard substance. 

The symptoms are a sudden arrest of the motions of the jaw, with the 
mouth about half open, the arrest of motion being accompanied or 
preceded generally with a sensation of slipping in one of the articula- 
tions. The chin is slightly inclined to the opposite side. The condyle 
may be felt somewhat advanced in its socket, and while it remains in this 
position the patient experiences some pain. 

In most cases the condyle resumes its place spontaneously, or after a 
slight lateral motion of the jaw ; but at other times it requires some little 
manual force to replace it. 

I have myself, during several years of my early life, while pursuing 
my studies at college, experienced this accident many times. It was 
peculiarly prone to occur in the morning, and it became necessary that I 
should eat with some care at my first meal. Sometimes the locking of 
the jaw was upon the right and sometimes upon the left side; it was 
always slightly painful. Generally the condyle was made to fall into 
place by a voluntary lateral motion of the jaw, but occasionally I was 
obliged to press gently against the chin with my hand. I never adopted 
any measures to remove the predisposition, but»as I became older the 
annoyance gradually ceased. 

Benevoli, in a dissertation published at Florence, Italy, in the year 
1747. describes another condition very analogous to this which we have 
now described, but which evidently depended upon a contraction of the 
muscles. A priest, having opened his mouth very widely in gaping, 
found himself unable to close it. A surgeon who was called diagnosti- 
cated ;t dislocation of the jaw, and attempted to reduce it, but failing, 
Benevoli was called, who, observing "thai the jaw was not absolutely 
immovable, that the articulations wore not separated, and that the chin 
did not incline outwards or toward the sternum," concluded that it was 
only a contraction of the depressing muscles. He therefore prescribed 
fomentations and oily unctions. The same night the temporal muscles 



646 I'ISLOCATIONS OF THE HYOID BONE. 

had acquired the size of a couple of eggs, from contraction, but the next 
day the patient could shut his mouth, and by the following day the tume- 
faction of the temporal muscles had also disappeared, and the restoration 
of the functions of the mouth was complete. 

Malgaigne, to whom I am indebted for the above case, relates two 
others, one in the person of the surgeon Mothe, and the other in a young 
man who was suffering from paralysis and spasmodic contractions of the 
muscles. Mothe observes that it had occurred to him very often, and 
that it still continued to happen sometimes, and when he gaped pretty 
widely, the genio-hyoid and mylo-hyoid muscles contracted with so much 
force as to render it impossible for him to close his mouth; these muscles 
being thus in a state of cramp, their bellies became hard under the chin, 
and so painful that he was obliged immediately to press upwards against 
the under surface of the chin in order to oppose their action. This con- 
dition would last from one to three minutes, and was relieved, generally, 
by frictions made with the hand over the contracted muscles. Some- 
times he actually believed that the lower jaw was dislocated, although 
the result always convinced him that it was not. 

Treatment. — In most or all of the cases of this peculiar derangement 
of the temporo-maxillary articulation, which have come under my notice, 
a spontaneous cure has been soon effected. It will be proper, however, 
in all cases, to instruct the patient to avoid using the jaw in a manner to 
produce the sensation of slipping; and if the general health is impaired, 
to adopt suitable measures to improve his condition. Cold water affu- 
sions to the side of the face and jaw would seem also to be rational 
measures, and I have generally recommended their use. 



CHAPTER III. 

DISLOCATIONS OF THE HYOID BONE (THYRO-HYOID 
ARTICULATION). 

So far as I know, Dr. Ripley, of South Carolina, and Dr. Gibb, of 
London, have alone furnished us with examples of this accident, but as I 
am unable to consult the original communications of either of these gen- 
tlemen, I will take the liberty of reproducing the brief summary of their 
papers contained in Mr. Durham's contribution to Holmes's Surgery. 1 

•• ( ribb 2 has recorded in the following words a case of dislocation of the 
hyoid bone in a patient under his care: 'The patient, a man, set. 45, 
would feci ;i sudden click in the left side of his neck, which produced a 
sensation ;i- if something was sticking in his throat. On examination, 
this appeared to me to depend upon a displacement of the left horn of 

1 Holmes's Surgery, 2d Amer. ed\, vol. ii. ]>. 400. Art. Injuries of the Neck. 

2 Gibb, on Diseases and Injuries of the Hyoid Bone, by G. D. Gibb, M.D., 
Churchill, London, 1H62, p. 20, and Trans. Path. Soc. London, vol. x. p. 66. 



DISLOCATIONS OF THE SPINE. 647 

the hyoid bone, and was generally reduced by throwing the head back- 
wards, toward the right side, so as to stretch the muscles of the neck, 
and then suddenly depressing the lower jaw, and so putting the de- 
pressors of the hyoid bone into operation. He died some years after of 
pulmonary consumption. On examining his throat ofter death, I found a 
sort of pouch, which answered the purpose of a synovial capsule, embrac- 
ing the horns of the left thyro-hyoid articulation. It was filled with a 
clear fluid, had a comparatively large rhomboid sesamoid bone developed 
in its outer wall, and permitted an extraordinary amount of motion.' 
This was the fourth case of the kind which had come under the notice 
of Gibb. All the patients were males. He subsequently met with a 
fifth case in which the patient was a female. 

''Reference is made in the work quoted to a paper, read in 1848 
before the Parisian Medical Society, by Dr. Ripley, of South Carolina, 
on 'Dislocations of the Os Hyoides, especially illustrated in his own 
person, and the manner of reducing them.' The latter process consisted 
in throwing the head backwards as far as possible, so as to place the 
muscles of the neck on the stretch, then relaxing the lower jaw, at the 
same time gently pressing or rubbing over the displaced part, when the 
displacement becomes reduced after a few attempts with a click. 

"Two cases of dysphagia described by Abercrombie are considered by 
Gibb to have been examples of double displacement of the thyro-hyoid 
articulation." 



CHAPTER IV. 

DISLOCATIONS OF THE SPINE. 

Delpech and Abernethy denied the possibility of a dislocation of the 
spine, either in the cervical, dorsal, or lumbar region, without the con- 
currence of a fracture. 

Says Sir Astley Cooper: "I have never witnessed a separation of 
"ii<' vertebra from another through the intervertebral substance, without 
fracture of the articular processes; or, if those processes remain un- 
broken, without a fracture through the bodies of the vertebrae." He 
would not. however, be understood to deny the possibility of a dislocation 
of the cervical vertebrae, their articular processes being placed more ob- 
liquely than those of the other vertebra'. 

The accident i-. no doubt, exceedingly rare, at least without the com- 
plication of a fracture, and it is not improbable that the actual number 
is -mailer than the reported examples would indicate. Those who make 
autopsies do not always perform their duties with that exact fidelity 
which might be necessary to determine so nice a point as a fracture of 
an oblique process, and it is quite likely that the circumstance may have 
been overlooked in some cases; hut ;i considerable number of well- 
authenticated examples of simple dislocations of cervical vertebrae have 
accumulated within the last fifty years. The reported examples of 



648 DISLOCATIONS OF THE SPINE. 

simple dislocations of the other vertebrae are not so numerous, nor as 
well attested. 

The causes are in general the same as those which produce fractures 
of the vertebrae, Buch as falls upon the head, feet, or back, and violent 
flexions of the spine backwards or to the one side or the other. 

Several examples are recorded of "spontaneous" dislocations, the 
result of some morbid changes in the bones or in the ligaments of the 
spinal column ; which accidents seem to belong more properly to general 
treatises upon surgery. 

The symptoms, also, partake of the same general character with frac- 
tures; the accident being accompanied with more or less complete paral- 
ysis of those portions of the body which receive their nervous supply 
from below the point at which the dislocation has occurred ; the spinal 
column presenting at the seat of displacement an angular projection or 
some form of irregularity ; and the distortion being attended with pain, 
especially when an attempt is made to move the body. 

In very many cases the symptoms are so nearly like those presented 
in a case of fracture, that the diagnosis is rendered exceedingly difficult. 
The presence or absence of crepitus may aid in the diagnosis, and yet 
it is well understood that this symptom is often absent in simple frac- 
tures, and that it may be present in all those examples of dislocation 
which are accompanied with a fracture of an oblique process, or of any 
other portion of the vertebrae, which class of examples constitutes a large 
majority of the whole number. 

There is usually present, however, in the dislocation, whether partial 
or complete, a peculiar fixedness or rigidity of the spine, which serves 
to distinguish this accident from a fracture of the spine as plainly as the 
preternatural rigidity of the limb in dislocations of the long bones, serves 
to distinguish these accidents from fractures of the same bones. The 
head or upper portion of the spinal column is bent forwards, or back- 
wards, or more commonly to one side, and in this position it remains 
immovably fixed until the reduction is accomplished. Sometimes, also, 
the surgeon may feel distinctly the lateral deviation of the spinous pro- 
cess, and, in the neck, the transverse processes become an important 
guide in the diagnosis. 

After these few general remarks, I shall proceed to speak of disloca- 
tions of the spine in the same order in which I have treated of fractures 
of the spine. 

§ 1. Dislocations of the Lumbar Vertebrae. 

Sir Astley Cooper plainly intimates that he does not believe a dislo- 
cation can occur in either the dorsal or lumbar region without the 
concurrence of a fracture, and Boyer affirms positively that it is "en- 
tirely impossible." 

Without wishing to insist upon the actual impossibility of these acci- 
dents, J am prepared to affirm that no well-authenticated case has yet 
been reported — at least of a complete dislocation, unaccompanied with a 
fracture of the articulating apophyses. I can conceive it possible that 
a lumbar vertebra may be dislocated forwards or backwards, and that a 



DISLOCATIONS OF THE LUMBAR VERTEBRJ. 649 

dorsal vertebra may be dislocated laterally, without a fracture; but 
neither of these events can be considered probable. It is certain, how- 
ever, that no evidence has yet been furnished of the actual occurrence 
of such a dislocation. 

Colquet mentions the case of a "tiler" who fell from the roof of a 
house backwards, and dislocated one of the lumbar vertebrae. This 
patient lived many years after the accident, and at the autopsy it was 
found that the second lumbar vertebra had been dislocated to the right by 
a movement of rotation about the left articular process, the two oblique 
processes of the left side preserving their connection, while those of the 
right were separated quite half an inch. The right vertebral plate was 
broken, and the canal of the vertebra was thus thrown open and 
widened. 1 

Dupuytren says that a man was crushed by the filling of a bank of 
earth upon his loins, when in the act of bending forwards. On the 
third day he was brought to Hotel Dieu, when it was observed that his 
lower extremities were completely paralyzed ; and that there existed in 
the upper part of the lumbar region a hard tumor, by pressure upon 
which a crepitus was manifest. A second tumor could be distinctly felt 
in front through the abdominal parietes, and the length of the spine was 
evidently diminished. This man died on the sixth day from a gradual 
asphyxia. When the body was examined it was found that the last 
dorsal and first lumbar vertebrae had been pushed forwards more than 
one inch, lacerating the spinal marrow, breaking the transverse and 
oblique processes of the last dorsal and first two lumbar vertebrae, and 
tearing off a small fragment of the body of one of the vertebrae where 
the intervertebral substance adhered to it. 2 

Vincent 3 presented in 1850 to the Anatomical Society of Paris a 
complex dislocation of the first lumbar vertebra, with destruction of the 
extremity of the spinal marrow, and interruption of the nervous func- 
tion of the cauda equina. Despite the most complete paraplegia the 
fracture became consolidated, and the patient survived eight months. 

These are all the cases of dislocation of the lumbar vertebras of which 
I am able to find any record. All were accompanied with fractures. 
In neither case was any attempt made to reduce the dislocation. In 
the second, it is scarcely probable that any means could have been em- 
ployed which would have succeeded in restoring the bones to their 
places ; nor is it probable that, if the bones had been restored to place, 
the patient would have survived the accident a day longer, probably not 
90 long. The cord was greatly lacerated, and the diaphragm torn up. 
and displaced, rendering a recovery almost impossible. 

In the first example, where the dislocation was less complete, and the 
complications less grave, could reduction have offered any reasonable 
chance for relief? By extension, combined with a movement of rotation 
in a direction opposite to that in which the displacement had taken 
place, it is possible that a reduction might have been accomplished. 

1 Cloquet, Malgaigne, op. cit.,t. 2, p. 890, from Journ. des Diflbrrnites de Maison. 
abe, torn. i. p 
- Dupuytren, Injuries and Diseases of Bones, Syd. ed., p. 340. 
3 Vincent, Bull. Soc. Anat., 1800 (Poinsot). 



650 DISLOCATIONS OF THE SPINE. 

The attempt certainly would have been justifiable ; but since the man 
lived "many years" without the reduction, it is doubtful whether the 
result of a reduction would have been more fortunate. 

§ 2. Dislocations of the Dorsal Vertebrae. 

Malgaigne enumerates twelve examples of dislocations of the dorsal 
vertebrae. I have found reported by American surgeons, at dates too 
recent to have been included in his analysis, two other examples (Poinsot 
has added three more cases, one reported by Thompson, of Dublin, 1 a 
second by Socin, of Bale, 2 and a third by himself. 3 In Thompson's case 
there was a complete dislocation of the twelfth dorsal upon the first lum- 
bar, with fracture of the spinous process, accompanied with rupture of the 
aorta and spinal cord. In Socin's case it was the eleventh and twelfth ; 
and in Poinsot's case there was dislocation forwards of the twelfth dorsal 
upon the first lumbar. A portion of the anterior and superior border 
of the first lumbar was torn off; the left articular and right transverse 
processes were also broken. The patient survived the accident twenty- 
four days. I am unable to subject them to a more complete analysis) ; 
but of this number only three are claimed to have been simple disloca- 
tions, unaccompanied with fracture. One of the fourteen was a disloca- 
tion of the fifth dorsal vertebra upon the sixth, one of the eighth, two 
of the ninth, five of the eleventh, and five of the twelfth ; the relative 
frequency of their occurrence in the different vertebrae corresponding 
with the observation of Weber, as to the points of the spinal column 
which allow of the greatest freedom of motion, and are consequently 
most liable to dislocations. The direction of the displacement in ten 
cases was observed to be six times forwards, twice backwards, and twice 
to the one side. 

Two of those which were unaccompanied with fracture, occurring 
respectively in the tenth and sixth dorsal vertebrae, were examples of a 
dislocation forwards, and the third, belonging to the ninth vertebra, was 
a dislocation backwards. A lateral dislocation without fracture has not 
been recorded. It is worthy of remark, also, that these three examples 
of uncomplicated dislocations, being all which our science up to this 
moment possesses, have happened in the experience of the same surgeon. 4 

A moment's consideration of the anatomy of these processes will 
render it apparent that even a partial dislocation forwards without a frac- 
ture of the oblique apophyses is impossible; and that in the direction 
backwards the dislocation can only occur to the extent of about one- 
quarter of an inch, constituting only a species of articular diastasis, without 
breaking off the articulating apophyses of the low r er corresponding ver- 
tebra. The first two examples, therefore, notwithstanding they have 
been received without question by Malgaigne, I shall unhesitatingly 
reject. The third, which alone carries evidence of its having been cor- 
rectly reported, and which was only a partial dislocation, is related as 
follows : "A mason, having fallen from a height in such a manner that 

1 Thompson, Dublin Journ. of Med. Sci., Oct. 1880. 

Socin, 3 Poinsot, op. cat, p. 754. 

4 Melchiori, Gaz. Medica, stati sardi, 1850. 



DISLOCATIONS OF THE DORSAL VERTEBRA. 651 

the lower part of his back struck upon the angle of the upper step of a 
ladder, died on the following day. After death it was observed that the 
spinous processes of the dorsal vertebrae were prominent down to the 
tenth : and that the tenth process with all of the processes below were 
depressed. It was also noticed that this depression, very marked when 
the trunk was thrown backwards, gradually diminished and finally dis- 
appeared altogether when the body was bent forwards. On removing 
the soft parts it was found that the ligaments were extensively torn asun- 
der and detached, so as to permit the articulating apophyses of the tenth 
vertebra to be carried into contact with the back of the ninth. The 
spinal marrow had undergone no visible alteration." 1 

Malgaigne thinks he has once observed the same thing in a living 
subject, and that by simply bending the body forwards he accomplished 
the reduction and effected a perfect cure, except that a slight curvature 
remained at the point of injury. 

Among the cases reported as having been complicated with fracture, 
the following example, reported by Dr. Graves, of New Hampshire, to 
Dr. Parker, of this city, possesses unusual interest : 

On the second day of January, 1852, a man, aet. 25, was struck on 
the back while in a stooping posture by a falling mass of timber, causing 
a dislocation of the last dorsal upon the first lumbar vertebra. His 
lower extremities were completely paralyzed, and priapism continued for 
several hours. The surgeon determined to make an attempt at reduction, 
and for this purpose he placed the patient upon his face, and secured a 
folded sheet under his armpits and another around his hips, directing 
four strong men to make extension and counter-extension by these sheets. 
Chloroform was administered, and when the patient was completely under 
its influence the extending and counter-extending forces were applied, 
and in a few minutes the vertebrae glided into place with a distinct bony 
crepitus. The restoration of the line of the vertebral column was found 
to be nearly but not quite perfect. 

On the sixteenth day he began to have slight sensation in his feet, and 
at the end of six or eight weeks he was able to control the evacuations 
from the bladder and rectum. Several months later he had recovered so 
completely as to walk with only the aid of a cane. 2 

I know of only one similar case. Rudiger has published an account 
of a dislocation obliquely backwards and to the right side, which occurred 
at the same point in the spinal column. The subject was a musketeer, 
who had been struck upon his back by a falling wall which he was en- 
deavoring to pull down. Rudiger laid him upon his belly, and with the 
assistance of others In- was aide, but not without causing pain, to reduce 
the bones. Immediately, however, when the extension was discontinued, 
the action of tin- muscles caused the displacement to recur. The surgeon 
then directed four men to make extension, while another man retained 
the bones in place by pressing upon them with his hands. After several 
hours this method of pressure was replaced by ;i board underlaid with 
compresses and sustaining ;i weight of more tnan fifty livres. On the 

: Bfelchiori, ]<>c. cit. 

2 Graves, X. V. Journ. Med , March, 18-72, p. 100. 



652 DISLOCATIONS OF THE SPINE. 

following day it was found sufficient to bind compresses over the project- 
ing bone, and in this condition the patient remained fifteen days; during 
all of which time he lay upon his belly with his shoulders more elevated 
than his pelvis. On the twentieth day he could lie upon his back, and 
in about six weeks lie was so completely restored as to be able to pursue 
his trade as before! 1 This is certainly a very extraordinary case, whether 
considered in reference to the means employed to restore the bones to 
place, or to its results ; and if the statements are to be received at all, it 
must be with some hesitation and allowance. 

On the other hand, we are able to present at least one example in 
which, although no reduction has been accomplished, the patient has 
survived the accident many years ; yet it must be admitted that his 
recovery is far from having been as complete as in the two cases just 
mentioned. 

Joseph Stocks, set. 11, in the spring of 1826, was crushed under the 
body of an ox-cart in such a manner as to produce a dislocation of the 
last dorsal from the first lumbar vertebra, causing immediately almost 
complete paralysis of all the parts below. This young man was seen 
by Dr. Swan, of Springfield, Mass., in the summer of 1834, at which 
time he was occupied as a portrait-painter. His lower extremities re- 
mained paralyzed and of the same size as at the time of the receipt of 
the injury. He w T as unable to sit erect, owing to the mobility of the 
spine at the seat of dislocation, and he had therefore lain constantly 
upon his side. The upper portion of his body was well developed, and 
his intellectual faculties were of a high order. 2 

It is not, however, with a life of perpetual deformity that the two 
examples of reduction already described are to be contrasted. A result 
so fortunate as this, where the bones remained unreduced, is unique ; in 
all the other cases reported the patients died miserably after periods 
ranging from a few days to one year or a little more. 

Charles Bell has related the case of an infant who was run over by 
a diligence, and who died thirteen months after the accident. On exami- 
nation after death, the last dorsal vertebra was found to be completely 
dislocated backwards and to the left, upon the first lumbar vertebra. 3 

With these facts before us, I think we cannot hesitate, when the nature 
of the accident is fully made out, and especially when the dislocation 
has occurred in the lower dorsal vertebrae, to attempt the reduction by 
forcible extension, united with judicious lateral motion, or with a certain 
amount of direct pressure upon the projecting spines. 

§ 3. Dislocations of the Six Lower Cervical Vertebrae. 

It is much more common to meet with simple dislocations of the vertebrae 
of the neck uncomplicated with fractures, than of either of the other ver- 
tebral divisions. This is doubtless owing to the greater extent of motion 
which their articulating surfaces enjoy. 

They may be dislocated forwards or backwards. The forward dislocation 

1 Rudiger, Journ dc Chir. de Desault, torn. iii. p. 59. 

2 Swan, Boston Med and Surg. Journ , vol. xxii. p. 102, March, 1840. 

3 Charles Bell, on Injuries of the Spine, 1824. 



OF THE SIX LOWER CERVICAL VERTEBRJE. 658 

may be complete or incomplete; with both sides equally advanced ("bi- 
lateral"' of Malgaigne), or one of the articulating apophyses may be dis- 
located forwards, holding the opposite apophysis in its place (" unilateral " 
of Malgaigne). 

Schrauth l has collected twenty -four examples of dislocation of the cer- 
vical vertebrae, of which four are recorded as dislocations forwards, two 
back, and six to the one side or the other. Three of this number were 
dislocations of the atlas, two were dislocations of the second vertebra, 
five of the fourth, two of the fifth, two of the sixth, and one of the 
seventh. In the other cases the seat was not stated. 

Malgaigne has brought together forty-five examples ; of which twenty-one 
were complete forward dislocations, nine incomplete forward dislocations, 
nine unilateral and forwards, and four were backward dislocations. Three 
were dislocations of the second vertebra upon the third, four were dis- 
locations of the third vertebra, ten of the fourth, eleven of the fifth, 
fifteen of the sixth, and two of the seventh. 2 

Causes. — The bilateral forward dislocations are generally caused by a 
fall upon the top and back of the head, or upon the top of the head 
while the neck is very much flexed forwards. 

The unilateral is caused sometimes by a direct blow upon the back 
of the neck, the blow being probably directed somewhat to one side or 
the other. 

It may also be caused by muscular action, and especially by the 
action of the sterno-cleido-mastoid, as in a sudden movement of the 
head to one side. Malgaigne has found this to have been the cause in 
six of the cases collected by him. Such also was the fact in the cases 
reported by Rotter, 3 Foelker, 4 Koch 5 , Schuh, Moxon, Berthold, and 
Wyeth, to the four latter of which I shall again make reference. 

The number of backward dislocations which have been reported are too 
few to enable us to indicate very accurately the general causes, but it 
seems probable that they are most often occasioned by a fall upon the 
fore and top part of the head, received while the neck is bent forcibly 
back. 

riptams. — In dislocations of the cervical vertebrae forwards the 
head i- usually depressed toward the sternum, in dislocations backwards 
the bead is thrown back, and in unilateral dislocations the head is 
turned over one of the shoulders. Neither of these malpositions of the 
head is uniformly present in these several dislocations, and indeed not 
nnfrequently, especially in case the system is greatly shocked by the 
accident, the head and neck assume a preternatural mobility, and may 
be turned easily in any direction. 

The spinous process, unless the patient is very fleshy or considerable 
swelling has supervened, can easily be felt, and its deviations to the 
right or to the left, forwards or backwards, furnish us with the most 
valuable and important sign of the dislocation. Even the transverse 
processes may be felt sometimes, especially in the upper partof the neck, 
with sufficient distinctiveness to render them useful in the diagnosis. 

1 Schrauth, Am. Journ. Med. 8ci., May. 1*4*. from Archiv fur Phys. Heilkunde. 

2 F->r additional cases Bee Dublin Journ. Med. Sci., March, 1879, p. 260. 

3 Poinsot, op. cit. ; p. 708. * Ibid. 5 Ibid. 



654 DISLOCATIONS OF THE SPINE. 

To these circumstances we may add paralysis of the body below the 
seat of injury, with pain and swelling at the point of dislocation. In 
some cases also the patient has himself distinctly felt a cracking or sud- 
den giving way in the neck at the moment of the accident. 

Prognosis. — The complete bilateral dislocations, whether backwards or 
forwards, have in most cases terminated fatally within a short time, gen- 
erally within forty-eight hours. Unilateral dislocations are less speedy in 
their results, but when the dislocation remains unreduced, death gener- 
ally takes place in a month or two. Lente relates a case of incomplete 
dislocation of the fifth cervical vertebra backwards, unaccompanied with 
fracture, which accident the patient survived five days. 1 A patient of 
Roux's lived eight days ; but in the case of a second patient mentioned by 
Lente, with a complete dislocation, without fracture, of the fifth vertebra, 
the patient survived the injury only two hours. 2 

On the other hand, occasional examples are presented of partial or 
complete recovery with the dislocation unreduced. 

Horner, of Philadelphia, presented to the class of medical students of 
the University of Pennsylvania, in 1842, a lad, aet. 10, who had fallen 
a distance of twenty feet, alighting upon his head. He was found sense- 
less and motionless, with his head bent under his body. He gradually 
recovered from the shock, but his neck was stiff, distorted, and motion- 
less, his face being inclined downwards to the right side. Two days 
after, his ''common and accurate perceptions returned, but he was 
' affected for some time with tingling and numbness in his left arm." 
When presented to the class the transverse processes, from the fifth 
upwards, were about half an inch in front of those below, showing that 
the left oblique process of the fourth was dislocated forwards upon the 
fifth. The rotary motions of the neck could not be executed to some 
extent, but much more freely to the right than to the left. Professor 
Horner refused to make any attempt to reduce the dislocation. 3 

Dr. Purple, of New York, has reported a case of what was called a 
dislocation of the fifth and sixth cervical vertebrae, producing complete 
paralysis of the lower part of the body, in which the patient survived 
the accident many years ; but his lower extremities were so useless and 
cumbersome as to induce him, in the year 1851, six years after the injury 
had been received, to submit to the amputation of both at the hip-joint. 
In 1852, having become very intemperate, he died, but no autopsy was 
obtained, so that the exact character of the injury was never ascertained. 4 
Sanson, of Paris, has reported also a case which came under his observa- 
tion at Hotel Dieu, of dislocation of the "third cervical vertebra back- 
wards," from which, although unreduced, the patient partially recovered. 
The character of this accident was not much better determined; for, 
although lie felt a Bevere and sharp pain at the moment of the injury, 
which was greatly aggravated by motion, and his head was bent forwards 
and to the left, "the chin being fixed on the upper part of the sternum," 
there was no paralysis of either the motor or sentient nerves. After 

1 Lente, New York Journ Med., May, 1850, p. 284. 2 Lente, Ibid., p. 397. 

3 Horner, Amer. Journ. Med. Sci., April, 1843, from Med. Exam. 

4 Purple, New York Journ. Med., May, 1853, p. 319. 



OF THE SIX LOWER CERVICAL VERTEBRAE. 655 

the lapse of about four months he left the hospital, still unable to lift his 
chin more than four inches from the sternum ; after which he resumed 
his usual occupations, suffering no further inconvenience than what was 
occasioned by the unnatural position of his head. 1 Notwithstanding the 
authoritative testimony of Sanson that this was a dislocation backwards, 
one cannot avoid the conclusion that it was either an incomplete unilateral 
dislocation, or perhaps a mere diastasis of the articulation, or else that it 
was an example of sprain of the muscles, and consequent contraction of one 
set, or paralysis of the opposing set of muscles. It is certain that it 
was not a complete dislocation; nor, since there was no paralysis of the 
body below the point of injury, can it be properly made use of as an 
argument for non-interference where such paralysis does actually exist. 

Poinsot saw. in 1883, a case almost identical in the phenomena which 
it presented with that of Ayres. to which I shall hereafter refer, occurring 
in a man aged 35 years, caused by the fall of a heavy weight upon his 
head while it was in a position of extension. He lost his consciousness 
at once, but when he recovered his senses after a few moments there was 
no paralysis. On the following day when examined by Poinsot, the 
symptoms seemed to point to a dislocation of the fifth cervical vertebra 
upon the sixth, but no attempt at reduction seems to have been made. 
Gradually the head regained its position and motions, but after a time, 
and at the date of the last observation, more or less of the deformity and 
immobility continued to exist. 2 

Treatment. — Let us see now what encouragement attempts at reduc- 
tion may oifer, in cases which present so little ground of hope where the 
reduction is not accomplished. 

Dr. Spencer, of Ticonderoga, N. Y., relates that a man, ret. 50, fell 
backwards from a board fence, striking upon the superior and anterior 
portion of his head, dislocating the second from the third vertebra of the 
neck. His head was thrown back so far as to prevent his seeing his 
own body, and all below the injury was completely paralyzed. Repeated 
attempts were made to reduce the dislocation, "but the transverse pro- 
- had become so interlocked that every effort proved abortive," and 
he died forty-eight hours after the injury was received. 3 Gaitskill also 
attempted reduction in a case of dislocation of the seventh cervical ver- 
tebra, but failed. 4 Boyer failed in two cases. It is related by Petit 
Radel, that a young patient at La Charite expired in the hands of the 
surgeons, upon such an attempt being made a few days after the acci- 
dent :' and Dupuytren says " the reduction of these dislocations is very 
5, ;ind we have often known an individual perish from the com- 
pression or elongation of the spinal marrow which always attends these 
attempts/ 9 

Dr. Schuh, of Vienna, relates that a man, »t. 24, while engaged at 
his work on December 5. 1838, twisted his bead suddenly round, in 
qnence of one of his companions roaring into his ear, when he in- 
ner. Journ. Med. 8ci., Feb. 1836, p. 514, from Gaz. elf- Hdpitaux. 

- ]' • .. ].. :<;i . 

Boston Med. and Burg. Journ., vol. xv. No. 11. 

4 Gaitskill, L aitory, vol. xv. p. 282. 

Petit Radel, Note to Boyer, Malad. Chir., vol. v. p. 118. 



656 DISLOCATIONS OF THE SPINE. 

Btantly felt something give way in his neck, and found it impossible to 
move his head. Next morning his head was turned to the right and 
bent down toward the shoulder. Every attempt to move his head 
caused great pain. He complained of weakness in his right arm, but 
all the other functions of his body were perfect. An attempt was im- 
mediately made to reduce the dislocation by lifting him by the head, 
but without success. On December 7th, the weakness and numbness 
of the right arm had increased, and the attempt to reduce the bones 
was renewed. The patient was laid horizontally upon a bed, and ex- 
tension made from the chin and occiput while counter-extension was 
made from the shoulders. The force thus employed was gradually in- 
creased until the patient and assistant felt a snap as of two bones meet- 
ing, when it was found that the head was restored to its natural position, 
and the power of moving it had returned. The next day his arm was 
more powerless than before, and on the following day he had vertigo, 
but these symptoms soon yielded to copious bleedings, and he left the 
hospital cured on the loth. 1 

Dr. Hickerman, of Ohio, has reported also, in the Ohio Medical 
Journal, a case of dislocation of one of the cervical vertebrae, the origi- 
nal account of which I have not seen, but only an abridged statement 
published in the Buffalo Medical Journal. By exploring the pharynx 
a prominence was felt opposite the junction of the fourth and fifth cer- 
vical vertebrae ; and the action of the heart was barely perceptible. 
Seizing the patient's head under his left arm, Dr. Hickerman in this 
manner made traction, while with the index finger of the right hand in 
the patient's throat, he made firm pressure obliquely upwards, back- 
wards, and to the left ; after continuing the pressure for about forty or 
fifty seconds, the part against which the finger was placed gradually 
yet quickly receded in the direction in which the pressure was made, 
and instantly, as quickly indeed as the act could be possibly executed, 
the patient opened her eyes, and natural respiration was established. 
She then also immediately became conscious of what was transpiring 
about her, and signified by signs, for she was yet unable to speak, that 
she had suffered pain in the epigastrium. Complete recovery took place.- 

Schrauth received under his care a patient who had a dislocation of the 
" right transverse apophysis " of the fourth cervical vertebra, without 
lesion of the spinal marrow T , which he reduced on the seventh day. The 
first attempt was unsuccessful ; but the second, made with great caution, 
by the aid of four assistants, three of whom pulled the head upwards 
while the fourth pressed with his whole weight upon the shoulders, was 
completely successful. During the time that the traction was being 
made, the head was occasionally rotated slightly and moved laterally, 
and at the same moment the surgeon pushed firmly against the displaced 
apophysis. The reduction was attended with "various distinct crack- 
ings in the neck," which were loud enough to be heard. After some 
days of repose he resumed his occupation, no stiffness remaining in the 
movements of the neck. 3 

1 Schuh, Amor. Journ. Med. Sei., July. 1811, p. 207. 

•-' Bickerman, Buff. Med. Journ., vol. x. p. 702, April, 1855. 

3 Schrauth, Amer. Journ. Med. Sci., May, 1848. 



OF THE SIX LOWER CERVICAL VERTEBRJB. 657 

According to Malgaigne, 1 Newman in 1814 and Seifert in 1831 have 
each reported one successful case, while Barny and Malgaigne have each 
met with two analogous examples successfully reduced. 

Dr. Edward Maxson, of Geneva, N. Y., was called, on the 28th of 
Oct. 1856. to see a child about nine years old, who had met with a sim- 
ilar accident about forty hours before, namely, a dislocation of the right 
articulating apophysis of the fifth or sixth cervical vertebra, occasioned 
by suddenly turning her head around while at play. She at first com- 
plained only of pain and inability to straighten the neck ; but whenever 
moved she became faint and irritable. A short time before the surgeon 
was called, the mother had, in attempting to move her in bed, turned the 
face a little more to the left, when a severe convulsion immediately en- 
sued. On examining the neck, Dr. Maxson discovered the displacement 
of the transverse process. Having advised the parents of the danger 
necessarily incident to an attempt at replacement, and of the probable 
consequences of its being permitted to remain as it was, they consented 
that the trial should be made. "I grasped the head," says Dr. Max- 
son, "with both hands, and proceeded according to Desault's method, 
only I first carried or turned the face very gently a little further toward 
the left shoulder, to, if possible, disengage the process ; then lifting or 
extending the head, I turned the face very gently toward the right 
shoulder, when the difficulty was at once overcome, and she exclaimed : 
• I can move my eyes.' Her countenance soon acquired a more natural 
appearance; the faintness passed off; she rested quietly through the 
night : had no return of the difficulty, and needed only an emollient 
anodyne to soothe the irritation and slight swelling which remained at 
the point of injury." 2 

Dr. Berthold, of Nuremberg, reduced a dislocation of one of the ob- 
lique processes of the sixth vertebra in a boy, set. 19, by extension with 
his hands and rotation. 3 

Dr. Wm. J. Morton, of New York, has reported a case of dislocation 
of the fifth oblique process in a boy twelve years old, reduced after the 
lapse of one week, by suspension of the head between the hands and 
rotation. 4 

Dr. John A. Wyeth, of this city, relates a case of dislocation of the 
right articular process of the fourth vertebra forwards, from muscular 
action, in the person of a lady who had turned her head strongly to the 
left side. Her head became fixed immovably; there was great pain at 
the point of this articulation; oppressed breathing and a numbness ex- 
tending down the arm of the same side. Dr. Wyeth was immediately 
summoned, and attempted to rotate the head into position, but was una- 
ble to do so. He then seized the head and rotated it slightly to the left, 
then made strong extension and rotated to the right, when the head 
returned to and retained its natural position. During the next two days 
there waa considerable pain along the spinal cord and in the right arm. 
Three months after the accident she was perfectly well. 5 

1 Malgaigne, op. cit., t. 2. 2 Maxson, Buffalo Med. Journ., Jan. 1.857, p. 476. 

" Berthold. Month. Ah. Med. Sci., June. 1876. 
♦ Morton, Med. Rec, Oct. 4. 1879. 
5 Wyeth, Hosp; Gaz., N. Y., Aug. 1879. 

42 



658 DISLOCATIONS OF THE SPINE. 

Rust, 1 Wood, 2 of this city, and others, have seen and reported similar 
cases at tended with like success. 

So far, the cases of successful reduction to which I have referred were 
examples of dislocation of only one of the articulating apophyses, and 
they have been sufficiently numerous and successful to establish the value 
of attempts at reduction. I have now to relate a case in itself almost 
unique, namely, a successful reduction of a dislocation of the fifth cer- 
vical vertebra, in which both apophyses appear to have been thrown 
forwards. It occurred in the practice of Dr. Daniel Ayres, of Brooklyn, 
X. Y., and will be best understood by a reproduction of his own pub- 
lished account of the case: 

" E. K., the subject of this accident, was a laboring man, thirty years 
of age, tall and muscular, but not fat, with a neck longer th^n the aver- 
age among men of equal height. On the evening of the 2d of October 
he became intoxicated ; was brought home insensible, and did not recover 
from the combined effects of the shock and his libations until the follow- 
ing morning, when he was supposed by his wife to be laboring under 
cold and a stiff neck. She made some domestic applications to the 
affected part, and administered a dose of cathartic medicine. When it 
was thought sufficient time had elapsed without obtaining relief, he was 
seen by Dr. Potter, of this city, and afterwards by Dr. Cullen, both of 
whom recognized a condition which was not only very unusual, but one 
which they had never before observed. I was then requested to examine 
the case, which I did on the ninth day after the accident. With some 
assistance and great personal effort, he was able to get out of bed, 
moving very slowly and cautiously. Desiring to expectorate, he was 
obliged to get down on his hands and knees, which he accomplished with 
the same deliberation. When seated in a chair, the head was thrown 
back and permanently fixed; the face turned upwards with an anxious 
expression. The anterior portion of the neck, bulging forwards, was 
strongly convex, rendering the larynx very prominent. The integu- 
ments of this region were exceedingly tense and intolerant of pressure. 
The posterior portion of the neck exhibited a sharp, sudden angle at the 
junction of the fifth and sixth cervical vertebrae, around which the integ- 
uments lay in folds. It was difficult to reach the bottom of this angle 
even with strong pressure of the fingers, and of course the regular line 
formed by the projecting spinous processes was abruptly lost. He com- 
plained of intense and constant pain at this point, which was neither 
relieved nor aggravated by pressure. With difficulty he swallowed 
small quantities of liquid, pausing after each effort, and could not be 
induced to take solid food, since the first attempt to do so after the accident 
was followed by violent paroxysms of coughing and choking. His 
breathing was obstructed and somewhat labored, being unable fully to 
clear the bronchi of their secretion. This, however, seemed rather an 
effect of the tense condition of the soft parts of the neck, than the result 
of pressure upon the spinal cord, since he presented no evidence of 
paralysis, either of motion or sensation, in parts below the neck. The 

1 East, Chelius, note by South. 

2 Wood, New York Journ. Med., Jan. 1857, p. 13. 



OF THE SIX LOWER CERVICAL VERTEBRAE. 



659 



Fig. 2G5. 



Bterno-cleido-mastoid muscles of both sides were felt quite soft and re- 
laxed. 

"But one conclusion could be formed upon this state of facts, to wit: 
that the oblique processes of both sides were completely dislocated. 
The marked rigidity of the head seemed to preclude the probability of 
fracture through the vertebral bodies, and although the cartilage might 
be separated anteriorly, yet the body not pressing backwards sufficiently 
to produce paralysis of the cord, it Avas hoped that the posterior verte- 
bral ligament remained uninjured ; it was, therefore, determined to make 
an effort at reduction on the following day. In addition to those origin- 
ally connected with the case, I am under obligations to Drs. Ingraham, 
Turner, Palmedo, G. D. Ayres, and a number of other medical gentle- 
men, who were present by invitation, all of whom confirmed the diag- 
nosis, and rendered efficient services. 

" The patient was placed upon a strong table, in a recumbent position, 
with a pillow resting under the shoulders, the head being supported by 
the hand during the administration of 
chloroform, of which an ounce was given 
before anesthesia ensued. Counter-ex- 
tension being made by two folded sheets 
placed obliquely across the shoulders 
and properly held, the head was grasped 
by one hand placed under the chin, the 
other over the occiput, and by steadily 
and firmly drawing the head directly 
backwards, and then upwards, an attempt 
was made at reduction, but failed for 
want of sufficient power. Dr. Ingraham 
was then requested to place his hands 
immediately over my own in the same 
position as before, and steady traction 
gain made in the same direction. 
Our united strength was required in 
drawing the head backwards and up- 
ward- to dislodge the superior oblique 
sea from their abnormal position. 
When this was felt to be yielding by Dr. 
Cnllen (who kept one hand constantly 
at the Beat of dislocation), Dr. Potter 
was directed to place his hands under 
our own, still in position, and assist in 
bringing the head forward- : at the same 
time the chest was depressed toward the table. The bones were dis- 
tinctly felt to slip into their places; the line of the spine was instantly 
red, the head and neck assuming their natural position and aspect. 
Aa soon as the patient became conscious, he expressed himself ignorant 
of what had taken place, bur free from pain, and, in his own Language, 
'all right.' A bandage was arranged to support the head and keep it 
bent forwards. He had an anodyne for two nights following, after which 
no further treatment was necessary, and al the end of one week be had 




Ayres's case of bilateral dislocation of 
the fifth cervical vertebra. 



060 DISLOCATIONS OF THE SPINE. 

complete control over the movements of the head and neck. Beyond 
the debility and emaciation immediately dependent upon protracted fast- 
ing and loss of rest, he has experienced no uneasiness since the operation. 
His appetite is now good, and all the functions perform their duty nor- 
mally. In a subsequent inquiry, to determine, if possible, the cause of 
the aecident, he states that he distinctly recollects going into a store in 
Atlantic Street, near the ferry, and there having angry words with an 
acquaintance ; that he left the store, and was proceeding up the street 
(which is here a rather steep ascent), when he was violently struck from 
behind, over the lower portion of the neck. He likewise remembers 
falling forwards, and striking against some object, but does not know 
what it was, nor what took place until the following morning." 1 

So far as I know, the only other example of supposed successful 
reduction of a complete bilateral dislocation of these vertebrae has been 
reported by Vrignonneau ; 2 but of which Malgaigne expresses some doubt 
as to whether it was an example of partial or complete dislocation. After 
alluding to Gosselin's success upon the cadaver, Malgaigne says : 3 " Some 
surgeons have even thought that they had obtained it upon the living 
subject. M. Vrignonneau was called to see a man 39 years of age, who 
had just fallen upon the head from a height of six metres. The face 
was bent upon the chest : the whole body was rigid, and was raised as 
if all of a piece ; the patient, however, could still move his limbs. The 
surgeon diagnosticated — but he does not say how — a dislocation forwards 
of the fifth cervical vertebra ; and at first he did not dare to interfere. 
The next day, however, all the limbs were paralyzed ; the following day 
death was imminent, as shown by the stertorous respiration and by the 
almost imperceptible pulse ; he then concluded to try the reduction, which 
was accomplished with a distinct craquement. From that time all the 
symptoms subsided as if by enchantment, and two months later the man 
could work, there remaining only some stiffness in the neck, especially 
during the lateral movements, which remained quite limited. I praise 
the fortunate determination of the surgeon ; but I regret that the diag- 
nosia was not more fully established; and even while admitting the 
forward dislocation, the absence of paralysis (?) leaves one in doubt as to 
whether it was not an incomplete dislocation, such as those we are about 
to consider." 

§ 4. Dislocations of the Atlas. 

Surgeons have met with several forms of displacement between the 
atlas and axis. First, a forced inclination forwards of the atlas upon the 
axis : in consequence of which the body or anterior arch of the atlas is 
made to recede from the odontoid process, and the transverse ligament 
glides upwards without breaking; so that the extremity of the odontoid 
process comes to occupy a position underneath or behind the ligament, 
and ill us presses upon the cord. It is apparent, also, that this form of 
displacement cannot occur without a rupture of the vertical ligaments 

1 Ayres, New York Journ. Med., Jan. 1857, p. 9. 

2 Vrignonneau, Journ. des Conn., Med. Chir., t. 1, p. 21. 
8 Malgaigne, op. cit, t. 2, p. 363. 



DISLOCATIONS OF THE ATLAS. (361 

which bind the transverse ligaments to the axis ; nor without a separa- 
tion of the atlas from the axis posteriorly and a rupture of the posterior 
atlo-axoidean ligament. Second, a similar inclination of the atlas, accom- 
panied with a rupture of the transverse and superior vertical ligaments, 
in consequence of which also the odontoid process is allowed to fall upon 
the cord. Third, the atlas in the same position, with the odontoid pro- 
cess broken at its base. Fourth, the atlas displaced directly forwards or 
backwards. Fifth, a displacement of only one articular process in a 
direction forwards ; and sixth, a displacement of one articular process 
forwards, and of the other backwards. 

I have already, when speaking of fractures of the atlas, or of the 
atlas and axis together, called attention to several examples of that form 
of the dislocation which is accompanied with a fracture of the odontoid 
process. The other forms of dislocation are characterized by so few 
symptoms peculiar to themselves, or which can be regarded as diagnostic 
and not already sufficiently studied in connection with other dislocations 
of the neck, that I shall not deem it necessary to do more than remind 
my readers, that if permitted to remain unreduced a speedy and fatal 
issue is inevitable, and to point them to some examples of recovery, after 
reduction has been fortunately accomplished. These may suffice to show 
that Dupuytren was in error when he declared that such accidents were 
wholly beyond the resources of our art. 

An old man received upon his head a bundle of hay cast from the top 
of a wagon. He fell with his head bent forwards so that his chin touched 
the top of the sternum, and in this position it remained immovably fixed ; 
all the other portions of his body preserving their natural functions. A 
surgeon, who was indeed the father of Malgaigne, being called, assured 
the patient, that unless he could give him relief he certainly would die ; 
but that inasmuch as the attempt might itself prove fatal, he ought at 
once to put in order his affairs. Accordingly the man partook of the 
sacrament; then the surgeon seated him upon the ground, and placing 
himself at his back with his knees resting upon his shoulders for the pur- 
pose of making counter-extension, and with a towel brought over his own 
shoulders and under the chin of the patient for extension, he proceeded 
to act upon the neck in the direction of the axis of the spine. The efforts 
were long and painful ; but at last, while the head was lifted as far as 
possible, it was suddenly drawn backwards, and immediately it resumed 
its natural direction. Absolute quietude was enjoined, and the patient 
recovered in a short time and without any accident. 

This patient was seen two years after by the younger Malgaigne, at 
which time no trace of the accident remained, except an impossibility of 
turning the head to the right or to the left. 

Another example i.s related by Ehrlich, but in this case the dislocation 
was backwards. A young man, aet. 16, while carrying a sack of flour 
up a ladder, fell backwards, and the sack falling over upon his face and 
head came to the ground before him. He was found lying with his head 
thrown back and to the right, the head resting upon the scapula of this 
side, but having so completely lost its "solidity" that by its own weight 
it would fall from one side to the other. On the front and left side of 
the neck there existed a prominence suposed to be formed by the atlas; 



t>62 DISLOCATIONS OF THE SPINE. 

the patient was unconscious; the pulse was scarcely perceptible, and the 
whole body was Buffering under paralysis. Ehrlich directed the shoulders 
to be held by one assistant, and the head to be drawn upon by another, 
while he pressed with his own hands forcibly upon the displaced atlas 
from behind. After several fruitless attempts, the reduction took place, 
accompanied with a sound distinctly audible to all of the assistants; the 
head resumed its position firmly, and the arms began to move. The head 
was afterwards maintained in place by a bandage. The cure proceeded 
rapidly, and after a time no trace of the injury remained but a disagree- 
able tension in the nape of the neck whenever he moved his head briskly 
to the one side or the other. 1 

Peabody, 2 in the case of a man who had subluxation of the atlas, 
occasioned by a fall from a height upon his head, and in whom death 
seemed imminent, succeeded after several trials. The patient was un- 
conscious, his eyes were closed, and his pupils dilated. Immediately 
upon the reduction having been effected, which was accompanied w T ith a 
violent craquement, the patient opened his eyes, spoke to those who were 
about him, and complained of pain in the back of his neck. On the 
following day he could be considered as in his normal condition. 

Uhde, Wagemann, and Boettger, of Braunschweig, report a case of 
bilateral dislocation of the atlas, in which the right inferior articular 
process of the atlas was displaced forwards, in front of the correspond- 
ing superior articular surface of the axis, and the left inferior articular 
surface of the atlas backwards, behind the corresponding superior articu- 
lar surface of the axis, as shown by the position of the left transverse 
process of the atlas. " The patient, a roofer, fell from a height of thirty 
feet. The head was rotated upon all three of its axes, the right half of 
the face being turned forwards, the facial line forming an angle with the 
median line of the body, and the chin thrown forwards, and the forehead 
backwards. On the left side there was paralysis of the plexus pharyn- 
geus and the hypoglossal nerve ; on the right, simply paralysis of the 
glosso-pharyngeus. Careful anatomical and experimental research 
proved that the injuries of the nerves depended upon the dislocation. 
The nervus accessorius W. also suffered at a point corresponding to that 
on the hypoglossus, and to this the paralysis of the left velum palati, 
observed in the patient, was attributed; the plexus pharyngeus, of which 
the anterior branch of the accessorius forms a part, suffering by traction 
on the trunk of the nerve. The experiments also proved that, in this 
dislocation the cord is not subjected to pressure, and that the vertebral 
artery is not injured. The dislocation was partially reduced two days 
after the accident by extension, extreme flexion of the head on the left 
shoulder, and rapid rotation backwards and to the right, together with 
direct pressure upon the left transverse process of the atlas. The condi- 
tion of the patient improved materially after extension had been made 
fur some time with Glisson's apparatus, After the lapse of several 
week- the patient was able to move his head in every direction. Barely 
a trace of the paralysis remained." 3 

1 Malgaigne, Ehrlich. Malgaigne, op. cit., torn. ii. p. 334. 

tody, Boston Mod and Surg. Journ., 1876, vol. 2, p. 79. 
3 St. Louis Courier of Med., Jan. 1879, from Arch, fur Klin. Chirurg., Sept. 1878. 



DISLOCATIONS OF THE EIBS. 663 

Bernhuber 1 treated a young man who had fallen, striking the back of 
his neck upon a piece of furniture. He lost consciousness, but when a 
point opposite the atlas was pressed upon he became convulsed. On the 
second day the convulsions were continuous, and death seemed imminent. 
The surgeon seized the head with both of his hands, and made traction 
upwards, when the patient opened his eyes and became conscious. By 
means of bandages and a gallows the head was maintained in that posi- 
tion. All symptoms at once disappeared, but it was observed that when- 
ever the extension ceased and the head was permitted to mil upon the 
trunk, the somnolency was prone to return, and for this reason the ex- 
tension was continued. The patient recovered, with only a slight rigidity 
of the neck. 

§ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean 
Dislocations. 

Lassus. Palletta, and Bouisson 2 have each reported one example of 
this dislocation. In neither case was the dislocation complete, but death 
occurred speedily in every instance. Dariste exhibited to the Anatomi- 
cal Society of Paris, in 1838, a specimen of incomplete dislocation of the 
occipito-atloidean articulation, with stretching of the transverse liga- 
ment; the patient from whom the specimen was taken having lived 
more than a year after the accident, when he died from a tubercle in 
the brain. 3 

Milner, of London, 4 has reported a case of complete dislocation of the 
head upon the atlas. A man, set. 38, fell from a height of seventy feet, 
and was killed instantly. On examination it was found that all the liga- 
ments uniting the occiput with the atlas were ruptured, and dislocation 
was complete. The posterior arch of the atlas was fractured; the spinal 
marrow, the two arteries, and the two vertebral veins were ruptured. 

It is unnecessary to say that only in examples of partial dislocation of 
the head could a hope be entertained that surgical resources would be of 
any avail; and even in these cases death has, in all the reported exam- 
ples, taken place too speedily to permit surgical interference. 



CHAPTER V. 

DISLOCATIONS OF THE EIBS. 

Thb rib- may bo separated from the bodies of the vertebne, from the 
cartilages of the ribs, and from each other. The cartilages of the ribs 
may also be separated from the sternum. 

1 Bernhuber. Denuce, Art. Kegion Atloidienne, Xouv. Die. de Med. et de Chir. 
Prat., t. ?,. p. 809. (Poinsot, op. cit., p. 772 

2 Lassos, Palletta, Bouisson. Malgaigne, op. cit., p. 320. 

3 Dari-u-, Amer. Journ. Mod. Sci., Nov. 1838, p. 237, from Archives Gen., May, 
1888. 

* Milru-r, St. Barthol. Hosp. Rep., vol. x. 



004 DISLOCATIONS OF THE KIBS. 



§ 1. Dislocations of the Ribs from the Vertebrae (Vertebro-Costal). 

The heads of the ribs are joined to the bodies of the vertebrae by 
strong ligaments. The articulations are ginglymoid, admitting of motion 
chiefly in the direction of the axis of the spine. The mobility gradually 
increases as we proceed from the first rib downwards to the last. Each 
joint is furnished with a capsule. 

The necks and tubercles are also united to the transverse processes by 
ligaments, and the articulations are furnished with synovial capsules. 

I am not aware that any examples have ever been reported of disloca- 
tions of the ribs from the transverse processes. 

Examples of dislocation of the heads of the ribs have been mentioned 
by Ambrose Pare, Bransby Cooper, Alcock, Donnie, Henkel, Kennedy, 
Buttet, and some others ; but most of these reputed cases have not borne 
the test of a critical analysis, and while Yidal (de Cassis) is in doubt 
whether the claims of even one have been fully established, Boyer denies 
absolutely its possibility. We see no reason, however, to question the 
authenticity of several of these examples. 

The case mentioned by Bransby Cooper, although very briefly nar- 
rated, leaves no room for doubt as to its real character. " Mr. Web- 
ster, surgeon to St. Albans, when examining the body of a patient who 
had died of fever, found the head of the seventh rib thrown upon the 
front of the corresponding vertebra, and there anchylosed. Upon in- 
quiry, Mr. Webster learned that this gentleman, several years before, 
had been thrown from his horse across a gate, for which accident he had 
been subjected to the treatment usually followed in fractures of the ribs, 
and there is every reason to believe that it was at this time the disloca- 
tion occurred." 1 

These accidents seem to have been generally occasioned by a fall or 
a blow upon the back, and the dislocation has been accompanied, usually, 
with a fracture of some other rib, or of the transverse or spinous pro- 
cesses of the corresponding vertebrae. The head of the rib has always 
been found to be displaced inwards. The lower ribs, including the false 
and floating, are those which have been most frequently displaced. 

It would be difficult, if not impossible, during the life of the patient, 
to make a positive diagnosis, since the symptoms resemble so closely 
those which accompany a fracture of the rib near its posterior extremity. 
The nature of the accident producing the dislocation, the depression, 
mobility, and pain, are equally indicative of a fracture; while the failure 
to detect crepitus might easily be explained by the thickness of the mus- 
cular walls at this point, or by the riding, or by other displacements of 
the broken fragments. 

Chelius speaks of a peculiar "rustling," perceived when the body 
and ribs are moved by the surgeon or by the patient himself, and which 
is different from the sensation produced by emphysema or fracture. 

The treatment ought to be the same which would be adopted in case 
the rib was broken. Replacement of the dislocated bone must be re- 

1 Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450. 



DISLOCATIONS OF THE CARTILAGES OF THE EIBS. 665 

garded as impossible ; and it only remains that we insure quiet as far 
as possible in this portion of the chest, and combat the pain and inflam- 
mation by suitable remedies. The circular bandage, however, recom- 
mended in these cases by Sir Astley Cooper, could only be serviceable 
in dislocations of those ribs which have an attachment to the sternum. 
The floating ribs, which have been found dislocated quite as often as 
either of the others, could derive no support from circular pressure, or 
from any other mechanical contrivance. 

§ 2. Dislocations of the Cartilages of the Ribs from the Sternum 
(Chondro-Sternal). 

The cartilage of the first rib has no proper articulation at either ex- 
tremity, but the remaining six upper ribs, where they join the sternum, 
are furnished with synovial capsules. In old age these articulations gen- 
erally disappear, but not always. 

Charles Bell observes: "A young man playing the dumb-bells, and 
throwing his arms behind him, feels something give way on the chest ; 
and one of the cartilages of the ribs has started and stands prominent. 
To reduce it, we make the patient draw a full inspiration, and with the 
fingers knead the projecting cartilage into its place. We apply a com- 
press and bandage, but the dislocation is with difficulty retained." 

Eavaton. Manzotti, and Monteggia have each, according to Malgaigne, 
reported one example of traumatic dislocation ; in all of which the carti- 
lages were thrown forwards in advance of the sternum. 

When treating of fracture of the sternum, I have related one case, 
which has come under my own observation, of dislocation of three or 
four cartilages at the same time. 

Dr. Samuel D. Flagg, of St. Paul, Minn., relates as follows : 

" During the evening of June 29, 1871, a girl, £et. 10, while playing 
with several children, ran violently against the corner of an ordinary deal 
table. It is stated that the child was faint and breathed with difficulty 
for a short time, but soon returned to play. No swelling or other evi- 
dence of injury was observed by her friends. 

u On the 1st of July, about forty-eight hours after receiving the injury, 
while exercising somewhat violently, she complained of sudden pain at 
the left costo-sternal articulation and a sensation of something having 
given way. Soon afterwards I saw the child for the first time, and found 
a slight non-crepitant swelling at the latter point, and the sternal extremity 
of the cartilage of the fourth rib displaced forwards, its posterior surface 
being very nearly on a plane with the anterior surface of the sternum. 
A minute fragment of bone, unconnected with the sternum or cartilage, 
was noticed, which I took to be a fragment chipped off from the margin 
of the articular depression on the edge of the sternum. Neither pain 
nor embarrassed respiration was notably prominent : crepitus could be 
detected, but not very distinctly ; preternatural mobility was very evi- 
dent." 1 

By pressure alone restoration has generally been effected, the cartilage 

1 Flagg. Xorth western Med. and Surg. Journ., Aug. 1871. 



666 DISLOCATIONS OF THE RIBS. 

resuming its position suddenly and with a sound. The reduction may, 
nevertheless, be facilitated by bending the trunk backwards, or by direct- 
ing the patient to make a full inspiration. 

To maintain the reduction has been found more difficult, and Sir Astley 
directs that " a long piece of wetted pasteboard should be placed in 
the course of three of the ribs and their cartilages, the injured rib being 
in the centre ; this dries upon the chest, takes the exact form of the 
parts, prevents motion, and affords the same support as a splint upon a 
fractured limb. A flannel roller is to be applied over this splint, and a 
system of depletion pursued, to prevent inflammation of the thoracic 
viscera." Instead of the pasteboard, we might use either felt, sole- 
leather, or gutta-percha. 

The patients spoken of by Ravaton and Manzotti were both cured in 
about one month. 

Mr. Bransby Cooper says that a baker's boy applied for relief at Guy's 
Hospital, who was the subject of displacement of the cartilages of the 
fifth and sixth ribs from their junction with the sternum, produced partly 
by the constant action of the pectoral muscles in kneading bread, but 
principally by his defective constitution. Mr. Cooper stated to the boy 
the necessity of changing his occupation, and advised him to go into the 
country ; but as he was unable to do so, little hope was entertained of 
his recovery. 1 

(The outer extremities of these cartilages being continuous with the 
bony structure of the rib, and destitute therefore of articular or synovial 
surfaces, may be subject to fracture, but not, properly speaking, to dis- 
location.) 

§ 3. Dislocations of one Cartilage upon Another. 

The cartilages on the sixth, seventh, and eight ribs are, furnished at 
their lower borders with a true arthrodial joint, by which they articulate 
with the corresponding cartilages. This arrangement sometimes extends 
to the fifth and ninth ribs. 

A displacement of these articulations may take place when one falls 
upon his back, striking upon some projecting body, so that the chest is 
suddenly thrown forwards; in consequence of which the upper margin 
of the lower cartilage is depressed and entangled behind the lower margin 
of the upper. The inferior cartilage is, therefore, the one which is dis- 
placed rather than the superior, although this latter, being made promi- 
nent by the pressure of the other from behind, seems alone to be dis- 
placed. Boyer, Martin, and Malgaigne 2 have each reported one example. 

It is probable that the contraction of the pectoral and abdominal 
muscles has ;i chief agency in the production of these dislocations, and 
that they are not solely or directly due to the shock of the accident. 

The treatment consists in pressing firmly upwards and backwards 
against the inferior margin of the upper, or overlapping rib, so as to dis- 
engage it from the lower, when by its own elasticity it will resume its 
natural position. The reduction might also be aided by a full inspiration. 

1 B. Cooper's ed. of Sir Astley Cooper, etc., op. cit, p. 447. 
- Malgaigne, op. cit., p. 398. 



DISLOCATIONS OF THE CLAVICLE. 667 



CHAPTER VI. 

DISLOCATIONS OF THE CLAVICLE. 

Of 57 dislocations of the clavicle observed and recorded by me, 13 
belonged to tlie sternal end and 44 to the acromial. Of those belonging 
to the sternal end, 11 were dislocations forwards, forwards and upwards, 
or forwards and downwards, and 2 were upwards. I have never met 
with a dislocation backwards. Of the acromial dislocations the whole 
number were dislocations upwards, or upwards and outwards. 

§ 1. Sterno-Clavicular. 
(a) Dislocations of the Sternal End of the Clavicle Forwards. 

Causes. — This accident is generally caused by a fall upon the point — 
outer surface — of the shoulder, in consequence of which the sternal end of 
the clavicle is driven forcibly inwards and forwards. It is probable, also, 
that the blow which produces the dislocation is received rather upon the 
anterior and outer than exactly upon the outer face of the shoulder. A 
sudden effort of the muscles, as in the attempt to balance a weight upon 
the head, or to throw the shoulders backwards when under drill, has 
been known also to produce this dislocation. In one example it was 
occasioned by placing the knee against the spine and drawing the 
shoulders forcibly back. Various other accidents, the philosophy of 
whose agency is not so easily explained, are said to have produced the 
same result : but it is not improbable that in many of these cases the 
precise manner in which the injury was received has not been correctly 
understood or reported. 

Mr. Fergusson has once seen this displacement in a newly born infant, 
which had happened during birth. It could be replaced with ease, but 
immediately slipped out again when left to itself. "Nothing was done; 
a new joint formed, and the child afterwards possessed as much power in 
the one arm as in the other;" 1 and Dr. W. C. Shaw, of Pittsburg, Pa., 
has also Been a congenital case. 2 

The following is an example of double forward dislocation at the sternal 
end: Agnes Moriarty, aet. 17, in a collision on the Third Avenue Elevated 
Railroad, March 25, 1879, was thrown violently, it is supposed, against 
the door, striking her left shoulder, and then by a rebound striking the 
floor of the car with the right shoulder. By courtesy of Drs. McGuire 
and King, her attending surgeons, I saw her on the fourth day after the 
accident. Exposing her Bhoulders, we observed an extensive ecchymosis 
on the outer surface of the right shoulder, extending some distance down 

m of Practical Surgery, Amer. ed., 1858, p. 203. 
2 Shaw. Med. Record, Aug. 18, 1877. 






DISLOCATIONS OF THE CLAVICLE. 



the arm. While seated in a chair both clavicles were subluxuated forwards 
and a little upwards, the right ascending a little higher than the left. 
She could not raise her arms to her head; but when lifted to this posi- 
tion the dislocations became complete, and when let fall the bones would 
resume their positions of subluxation with a click. The bones could not 
be pushed completely into their sockets, and pulling the shoulders back 
increased the displacement; but when lying flat on her back they went 
nearly into place. At my suggestion, she was kept in this position six 
weeks, hut with no result; the bones still becoming displaced whenever 
she got up. Some months after the accident she was still suffering from 
the general disturbance to her spine and nervous system caused by the 
shock, and the arms had not recovered their original strength. 

It seems probable, from the history of the case as subsequently ascer- 
tained, that there had existed prior to the accident a laxity of the cap- 
sule, permitting of the existence of a partial displacement, and which 
was rendered complete by the traumatism. 

Symptoms. — The head of the bone, unless the person is exceedingly 
fat. or great swelling has supervened, can be distinctly felt and seen in 
front of the sternum; the corresponding shoulder falls a little back; the 
head inclines also sometimes to the same side; the movements of the arm 
are embarrassed, and accompanied almost always with an acute pain at 
the point of dislocation. The clavicular portion of the sterno-cleido- 
mastoid muscle presents an unusually sharp and projecting outline, and 
a careful measurement indicates, if the dislocation is complete, a sensible 
approach of the acromion process toward the centre of the sternum. If 
now the surgeon places his knee against the spine, and draws the shoul- 
ders back, the projection of the clavi- 
cle in front usually diminishes or dis- 
appears ; if he carries the shoulder up, 
it descends ; and if he depresses the 
shoulder, it ascends. 

The simplicity and uniformity of the 
symptoms which usually characterize 
this accident will generally prevent the 
possibility of a mistake; but Pinel 
mentions the case of a man who, hav- 
ing presented himself at one of the hos- 
pitals of Paris, suffering under this 
dislocation, the surgeon-in-chief thought 
it a tumor of the bone, and advised the 
application of a plaster; and, on the 
other hand, a patient presented himself 
elpeau, who had been treated for a dislocation, when the bone was 
only expanded by disease. I have myself also seen a fracture so near 
the -tonal end of the bone as not to be easily distinguished from a 
dislocation. 

Pathology. — In complete anterior dislocation of the clavicle, the cap- 
sular Ligament suffers a complete disruption, and also the anterior with 
the posterior sterno-clavicular liniments. The rhomboid and interarticu- 
lar Ligaments suffer more or less, according to the extent of the displace- 



Fig. 266 




Dislocation of the sternal end forwards. 



DISLOCATIONS FOEWAEDS AT THE STERNAL END. 669 

uient. The interarticular cartilage may retain its attachment to the 
sternum, or it may be carried forwards with the clavicle. The head of 
the bone lies immediately underneath the skin and in front of the ster- 
num : and generally it is found to have descended a little upon its ante- 
rior surface. Richerand saw a case in which the sternal extremity of 
the bone was placed three inches below the top of the sternum. In some 
cases it is situated in front and a little above the sternum. 

Wherever the bone lies, it carries with it the clavicular fasciculus of 
the sterno-cleido-mastoid muscle. 

Treatment. — Xot one of the 11 forward dislocations of the clavicle at 
the sternal end seen by me has been completely reduced, or if reduced 
they have not been retained in place. In the following example the 
reduction, although faithfully attempted, was never accomplished. 

Mr. H., of Buffalo, set. 45, was thrown by a horse, suffering at the 
aame moment a fracture of the leg and a forward dislocation of the left 
clavicle at its sternal end. 

Prof. James P. White, with whom I was in consultation, made several 
attempts to reduce the dislocation by placing the knee against the spine 
and pulling the shoulder forcibly back, and the same efforts were repeated 
by myself, but without accomplishing the reduction. We also endeavored 
to reduce it by pressing directly upon the projecting bone and by placing 
a pad in the axilla, using the arm as a lever, as recommended by Desault, 
and with no better result. 

The patient was tolerably muscular, but while we w T ere manipulating 
he was very much enfeebled by the shock of the accident. 

Finding that it was impossible to reduce the dislocation by any mode- 
rut, amount of force, and believing that if it were to succeed we could 
not retain the bone in place, and the more especially because his left 
much bruised that he could not bear an axillary pad or ban- 
f any kind, we desisted from any further attempts. 

Two years later I examined the shoulder and found the clavicle still 
unreduced, and it- position unchanged. W T hen he carries the shoulder 
forwards or backwards, there is a corresponding motion at the sternal 
end of the clavicle. The arm is not quite as strong as the other, and its 
freedom of motion is alightly impaired. 

I have also in my museum the cast of a case of complete forward dis- 
on a? this point: which accident occurred in a lad twelve years old, 
who had fallen into a cellar on the 20th of August, 1856. The late 
Dr. Lewis and Dr. Dayton, both excellent surgeons, had examined the 
and dressings had been applied with a view to maintain the reduc- 
tion; but on the fifth day after the accident T found the bone displaced; 
nor do 1 think reduction was ever afterwards maintained. 

A lad was brought into the Buffalo Hospital of the Sisters of Charity, 
with ;i dislocation of the aame character, on tin- 25th of Sept. 1858, 
who had been run over by ■ wagon on the same day. Dr. E. I'. Smith, 
:' the Burgeons of the hospital, attempted faithfully to reduce it, 
but was unable to do bo. Five days after, I found the bone out and 
movable. All apparatus having been removed, we laid him upon 
his back in bed, and kept him in this position three weeks. He was 
then dismissed with no change in the appearance of the bone, but he 
could move the arm as well as before the accident. 



670 



DISLOCATIONS OF THE CLAVICLE. 



Other surgeons have not met with, or, at least, they have not mentioned, 
any cases in which the reduction of this dislocation was attended with 
difficulty, nor am I prepared to explain the difficulty which was experi- 
enced in my own (Mr. H.), and in Dr. E. P. Smith's case. Unless it be 
as suggested by Sedillot, and as illustrated by Smith's case of dislocation 
upwards hereafter to be mentioned, that the reduction was prevented by 
the displacement of the interarticular cartilage. But most surgeons 
have testified to the difficulty of retaining it in place when reduction has 
been fairly accomplished. Chelius says, "there commonly remains more 
or less deformity," and Malgaigne says that "it is difficult and rare to 
cure it without deformity." 

Nevertheless, Desault (or, rather, his pupil Bichat, who has published 
his lectures), who always speaks very confidently of his ability to retain 
either broken or dislocated bones in their places, says that he " almost 
always obtained complete success" with his apparatus. It is remarkable, 
however, that of the three examples furnished by Bichat to confirm this 
statement, all of which were treated by Desault himself, one recovered 
after a long time with a " very perceptible protuberance in front of the 
sternum," one with a "very slight protuberance," and in the other the 
"swelling was almost gone" on the twentieth day, and we are left in 
doubt as to whether the reduction was any more complete than in either 

of the other cases. 1 Richerand 
FlG - 267 - and Guersant succeeded no better 

with Desault's dressings. 2 

Other surgeons have made sim- 
ilar claims for their own forms of 
apparatus, but experience still 
continues to show that a com- 
plete retention of the dislocated 
bone is seldom to be expected. 

Sir Astley Cooper recommends 
an apparatus, the construction 
and application of which are 
illustrated by the accompany- 
ing sketch, the object of which 
is to draw the shoulders back, 
and at the same time, by the aid 
of two pads or cushions in the 
axilhie, to carry the shoulders 
outwards. The dressing is then 
completed by placing the arm in 
a sling. He advises, however, 
that in some way direct pressure 
should be made upon the pro- 
jecting point of bone. 

Velpeau objects to any plan 
which will draw the shoulders back; but, on the contrary, he thinks that 
the shoulders should be kept slightly forwards, so as to diminish the 

1 Desault on Fractures and Dislocations, by Xav. Bichat, Philada. ed., 1805, p. 52. 
* .Malgaigne, op. cit., torn. ii. p. 417. 




Sir Astley Cooper's apparatus for dislocated 
clavicle. 



DISLOCATIONS UPWARDS AT THE STERNAL END. 671 

tendency of the sternal end of the clavicle to escape in this direc- 
tion. 

Until further observations have determined the relative value of these 
and of many other processes, it will be well to adopt no fixed rule of 
action : but having reduced the bone by either placing the knee upon the 
spine and drawing the shoulders back, or by making use of the humerus 
as a lever, the surgeon should attempt to maintain it in place by such 
means as the experiment shall prove are most successful. Among these 
means, direct pressure upon the sternal end of the clavicle, the sling, and 
perfect quietude of the muscles of the arm through the aid of bandages, 
with the dorsal decubitus, are no doubt of the greatest importance. If 
we find that a position of the shoulders more or less forwards or back- 
wards best maintains the apposition, this position, whatever it is, ought 
to be continued. 

In order to be successful, sufficient time must elapse for the torn liga- 
ments to become firmly reunited, during which the reduction must be 
constant ; since every time the bone escapes, the whole work of repair 
has to be recommenced as from the beginning. To this end at least four 
or six weeks are necessary, and sometimes the period must be lengthened 
far beyond these limits ; so that it may often become a grave point of 
inquiry whether the long confinement of the limb will not entail more 
serious consequences than have ever been known to arise from leaving 
the bone displaced. In no case seen by me has the function of the arm 
been very seriously impaired by the displacement. 

(b) Dislocations of the Sternal End of the Clavicle Upwards. 

R. W. Smith 1 has furnished us with an account of one example of this 
dislocation as seen in the dissection. The extremity of the left clavicle 
rested upon the sternum, and had passed the median line until it touched 
the sterno-cleido-mastoid muscle of the right side. Posteriorly it rested 
upon the sterno-hyoideus muscle and the front of the trachea. The 
anterior and posterior ligaments of the joint, as well as the rhomboid 
ligaments, were torn. The interarticular cartilage was detached from 
the stem inn and the cartilage of the first rib, and had followed the 
clavicle. 

Malgaigne 1ms collected four undoubted examples of this dislocation. 
Mr. Bryant mentions two cases seen by himself, one of which was a 
double dislocation. He refers also to a specimen in Guy's Museum, 
dislocated upwards and forwards. 2 Dr. Shaw, of Pittsburg, Pa., has 
reported one case in an adult caused by a fall. 3 Vanvert has reported 
'razette des Hopitaux, caused by a blow upon the side of 
th<- chest, which he was unable to reduce. 4 I have been unable to find 
a report of any other except the very extraordinary case described by 
Dr. Rochester, at the September meeting of the Buffalo Medical Asso- 

' Smith, Dublin Journ. of .Med. Sci., Dec. 1872. 

.at. Practice of Surgery, p. 787, London, 1872. 
Med. Record, Aug. 18, 1877. 
* Vanvert, New York l£ed. Journ., March, 1879, p. 320. 



672 DISLOCATIONS OF THE CLAVICLE. 

ciation, and which case, through the courtesy of Dr. Rochester, I was 
permitted to see several times. 1 

Jerry McAuliffe, set. 44, on the 28th of August, 1858, while seated 
upon a load of wood, was caught under the bar of a gateway and violently 
crushed, the right shoulder being forced downwards and a little back- 
wards. Dr. Rochester saw him very soon after the accident. On ex- 
amination, it was found that the sternal extremity of the right clavicle 
was thrown upwards so far as to rest upon the front of the thyroid carti- 
lage, occasioning considerable pain, difficulty of respiration, and loss of 
speech. Reduction was easily effected, and a retentive apparatus was 
immediately applied, consisting of a gutta-percha splint, moulded to the 
clavicle and ribs, and retained in place with adhesive plaster. Suitable 
bandages, a sling, etc., were also employed to maintain complete rest. 

Notwithstanding all the care employed, the bone again became dis- 
placed, and when, nearly four months after the accident, this man came 
before the class of medical students at the Hospital of the Sisters of 
Charity, we found the sternal end of the clavicle carried upwards half 
an inch, and across toward the opposite side also about half an inch, 
and projecting somewhat in front. It was fixed in this position by liga- 
ments which allowed it to move much more freely than natural, but 
which would not permit any great displacement. The corresponding 
shoulder was slightly depressed. McAuliffe said that he felt no incon- 
venience or abatement of strength in the arm except when he attempted 
to lift weights above his head. 

In April, 1870, I met with a similar case in a woman fifty years of 
age, which had been caused by a fall upon the shoulders nine weeks 
before, and which had been overlooked by her surgeon in the first in- 
stance. When seen by me it was immovably fixed in its new position. 

The accident seems to have been produced, in all the cases, so far as 
can be ascertained, by a force operating upon the end and top of the 
shoulder ; in consequence of which the head of the clavicle is pushed and 
at the same time lifted, as it were, from its socket, tearing not only its 
capsule with the ligaments which immediately invest the capsule, but 
also in some instances the costoclavicular ligament with some fibres of 
the subclavian muscle. The sternal end of the clavicle is found riding 
upon the top of the sternum, its head being placed between the sternal 
fasciculus of the sterno-cleido-mastoid muscle on the one hand, and the 
sterno-hyoid muscle on the other. In one of the cases seen by Mai- 
gaigne, the head had traversed in this direction completely the intra- 
clavicular space, and lay behind the sternal portion of the opposite 
sterno-cleido-mastoid muscle. 

Symptoms. — The symptoms are, a depression of the shoulder, with an 
elevation of the sternal end of the clavicle so as to increase sensibly the 
<\>ncc between it and the first rib. The clavicle also encroaches more or 
less upon the supra-sternal fossa, occasioning a corresponding diminu- 
tion of the space between the end of the shoulder and the centre of the 
sternum. The sternal portion of one or both of the sterno-cleido-mastoid 

1 Rochester, Buffalo Med. Journ., vol. xiv. p. 262 



OF THE STERNAL END OF CLAVICLE BACKWARDS. 673 

muscles may also be seen raised and rendered tense by the pressure of 
the head of the bone from behind. 

Treatment. — Reduction has been found easy, but Malgaigne thinks a 
perfect retention impossible — at least it does not seem to have been 
accomplished in any of the cases reported. In no case did the displace- 
ment seriously impair the functions of the arm. 

The same apparatus to which I shall give the preference in cases 
of dislocation upwards of the acromial end of the clavicle, at least with 

Fig. 268. 




Dislocation of the sternal end of the clavicle upwards. 

only such slight modifications as the peculiarities of the case will natu- 
rally suggest, will be suitable for this accident. The shoulder must 
be lifted by a sling, while the sternal end of the clavicle is pressed 
downward- by a pad and bandages; and all the muscles of the arm 
and chest, so far as is consistent with respiration and comfort, must be 
maintained in a state of perfect rest until the ligaments have become 
reunited. 

'[.-LOCATIONS OF THE STERNAL END OF THE CLAVICLE BACKWARDS. 

The first case upon record of this kind of accident, caused by violence, 
was published by Pellieux, in 1834, in the Revue Medicate; until which 
time it- existence bad been generally denied. In the London and 
Edinburgh Journal of Medical Science for October, 1841, several cases 
are mentioned. 

Two forms of the accident have been described; one in which the head 
of the clavicle is driven backwards and a little downwards, and another 
in which it is displaced directly backwards, or backwards and a little 
upwards. In both of these classes, the end of the bone falls inwards 
toward the opposite clavicle, and occupies a space in the cellular tissue 
bark of the Btemo-hyoid and sterno-thyroid muscles, and in front of the 
oesophagus; the trachea, if reached at all, being probably thrust to the 
opposite side. 

The examples in which it lias been found below the top of the sternum 
are much the mosl numerous; indeed, it is probable that the other form 

1.; 



1.74 DISLOCATIONS OF THE CLAVICLE. 

is only a secondary displacement, occasioned by the action of the fibres 
of the Bterno-cleido-mastoid muscle. 

Causes. — Of the eleven examples mentioned by Malgaigne, four were 
occasioned by direct blows, and most of the remainder by crushing acci- 
dents, as by powerful lateral compression of the shoulders. 

One of the eases produced by a direct blow was accompanied with an 
external wound, and is the only instance of a compound dislocation of 
this kind which I have found upon record. The man was admitted into 
St. Thomas's Hospital in Sept. 1835, and, according to his own account, 
the sharp end of a pickaxe had been driven through the flesh against the 
bone. The sternal end of the clavicle was found to be displaced back- 
wards, and with the finger thrust into the Avound on the front of the chest, 
it could be distinctly felt resting upon the side and front of the trachea, 
where it interfered somewhat with respiration and deglutition. He had 
a great desire to cough, with a sensation of pressure on his windpipe, 
which was greatly increased when his head was thrown back. There 
was also a slight emphysema in the region below the collar-bone and over 
the top of the sternum. The shoulder having been brought back with 
straps attached to a back -board, the bone readily resumed its place. The 
elbow was then brought forwards and bound to the side, and the w r ound 
being closed with adhesive plaster, he was put to bed with the shoulders 
much raised. No unfavorable symptoms followed, and in three weeks 
he left his bed. Three w^eeks later he left the hospital with the sternal 
end of the bone still falling a little backwards, and rather more movable 
than natural. 1 

The following example, related by Morel-Lavallee, will illustrate that 
class in which the dislocation results from an indirect blow, or from a 
crushing accident. 

Lemoine. seventeen years old, had his right shoulder violently pressed 
against a wall by a carriage. He experienced at the moment some pain 
at the bottom of his neck, and a great sensation of suffocation, which 
lasted for more than a quarter of an hour. The dyspnoea gradually sub- 
sided, but the motion of the right arm not returning, he, on the eighth 
day after the accident, entered La Charite. On examination, the two 
shoulders were found to be on the same level, but the right one was 
nearer the median line. The internal extremity of the clavicle was half 
concealed behind the sternum. On depressing the shoulder, the inner 
end of the clavicle arose and disengaged itself from behind the sternum; 
but reduction was effected by elevating the shoulder, while at the same 
time it was carried outwards and backwards. Desault's bandage was 
th. -n applied, bul as it became loosened Velpeau's was substituted, which 
kepi the hone completely in position until the eighteenth day, when the 
patient was lost sight of. 2 

Symptoms. — The most constant symptoms are, the absence of the 
head of the hone from its socket, and its complete or partial disappear- 
ance behind the sternum, an approach of the corresponding shoulder to 
the median line, an inclination of the head to the opposite side, elevation 

1 South, note to Chelius's Surgery, Amer. ed., vol. ii. p. 218. 

2 Morel-Lavall6e, Amer. Journ. Med Sci.,vol. xxix. p. 229, 1842; from Graz. Med. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 675 

of the shoulder, pain at the bottom of the neck, impairment of the motions 
of the arm, sometimes difficulty in respiration and in deglutition, partial 
arrest in the circulation of the arm from pressure upon the subclavian 
artery, and a slight projection of the acromial end of the clavicle, noticed 
twice by Morel-Lavallee. 

Treatment. — It has not generally been found difficult to reduce this 
dislocation, nor, -when reduced, is it so liable to become again displaced 
as are the dislocations forwards ; yet in only a few instances has the 
restoration been so complete as not to leave some deformity. 

In order to the reduction, the shoulder must be carried generally up- 
wards, outwards, and backwards ; and it may then be best maintained in 
position by laying the patient on his back upon an elevated cushion, as 
practised by Tyrrell in the case related by South. To this may be added 
such other measures, differing but little from those employed in other 
dislocations of the clavicle, as are necessary to insure complete rest to 
the muscles. Of course, no pads or bands across the clavicle can be of 
any service in this case. 

As in the other cases of dislocation at this point, the patients have 
generally recovered nearly the full use of their arms, even in one or two 
instances in which the reduction has never been accomplished. 

^ 2. Acromioclavicular. 

(a) Dislocations of the Acromial Exd of the Clavicle Upwards. 

Of all the dislocations of the clavicle, this form is most frequent, I 
have met with it either as a partial or complete traumatic luxation forty- 
three times. The youngest subject was seven years of age, and the 
oldest sixty-three. All but two were males. 

I have seen one example of congenital complete upward and outward 
dislocation of the acromial end, which was not traumatic — the case of 
Mary Ann Hughes, who was examined by me Feb. 8, 1876, when she 
was four weeks old. The labor had been easy and natural, and there 
was no soreness over the joint. It was easily reduced, but could not 
be maintained in place. 

■'see. — It is produced generally by a fall upon the extremity of the 
shoulder. Twice the blow li;is been received rather upon the back than 
upon the extremity, and once it was occasioned by the fall of a board 
directly upon the top of the shoulder, and once by a bolt thrust directly 
up from under the clavicle. 

Symptoms. — When the dislocation is complete, the clavicle not only is 
lifted from its articular facet to the extent of the breadth of the bone, 
but it La pushed more or less outwards over the top of the acromion pro- 
rally Less Than half an inch, but I have once seen it riding the 
the extent of three-quarters of an inch. In this last example, 
the case of James Moran, a strong, healthy laboring man. the clavicle 
av;i^ easily reduced, and it always went into place with a sensible click : 
but although every possible care was taken to retain it in place by band- 
-. an axillary pad. and a sling, yet it was not accom- 



676 DISLOCATIONS OF THE CLAVICLE. 

plished, and od the third day he removed all the dressings, and refused 
to have them reapplied. 

I have usually found the shoulder slightly depressed; and in one in- 
stance, where it is probable the deltoid muscle had suffered some injury, 
the elbow hung away from the body, and any attempts to lay it against 
the side produced an acute pain in the shoulder. 1 It has been noticed 
also, in most cases, that the clavicular portion of the trapezius muscle 
appeared lifted and tense, especially when the neck was straight. 

Inability to raise the arm to a right angle with the body is a general 
but not constant symptom. In two instances, where the displacement 
was only moderate, the patients were at first and for some time after- 
wards unable to lift the arm in any degree from the side. In one 
example, a lady sixty years of age had fallen upon her shoulder and pro- 
duced a dislocation upwards, but she had not consulted a surgeon until 
she called upon me, five months after the accident. The clavicle was 
then raised from its socket about half an inch, but it could be easily 
pressed back to its place, the reduction being attended with a grating 
sensation, a circumstance which I have not noticed in any other instance. 
She was not even then able to raise her arm to her head, nor had she 
been able to do so since the accident occurred. 

In all the motions of the arm and shoulder, the clavicle is seen to 
move more freely than natural immediately under the skin, and these 
motions are usually attended with some pain at the point of dislocation. 

This accident has been sometimes mistaken for a dislocation of the 
humerus, but, unless the shoulder is already greatly swollen, the error 
is not likely to happen. If the point of the acromion process can be 
made out,, it will be easy to determine, by sliding the finger along its 
spine, whether the clavicle is displaced or not, and by these means to 
settle the question of its complicity in the accident. The question as to 
whether the shoulder is dislocated or not may be more difficult of solution, 
as we shall hereafter have occasion again to observe. 

Pathology. — Generally there exists simply a rupture of the ligaments 
immediately investing the joint, so that the clavicle rises from its socket 
only about half an inch, more or less, according to its diameter, and is 
carried outwards just sufficiently far to allow it to rest upon the upper 
margin of the acromial articulation. In at least thirty of the cases seen 
by me this has been the position of the acromial end of the clavicle, and 
for its complete reduction nothing more has been required than to press 
with moderate force upon the upper and outer end of the bone. 

In nine cases I have found the bone not only thus lifted in its socket, 
hut also driven over upon the acromion process from half to three- 
quarters of an inch : and in one instance, that of a gentleman, Mr. B., 
who was injured in a railroad accident, the acromial end of the clavicle 
was displaced outwards half an inch and backwards three-quarters of an 
inch, while the sternal end also was considerably lifted in its socket and 
slightly sent inwards. The shoulder fell forwards and the coracoid pro- 
was one inch nearer the sternum than the same process upon the 

1 Report on Dislocations, by the author. Transac. of New York State Med. Soc. 
1855, p. 19. 



OF THE ACROMIAL EXD OF CLAVICLE UPWARDS. 



677 



opposite side. In such cases more or less of the fibres of the coraco- 
clavicular ligament must have suffered a disruption: indeed, without a 
rupture of its external fasciculus, which anatomists have called the trape- 
zoid ligament, such a dislocation cannot take place. 

M. Nicaise 1 has reported a case analogous to the above, in which he 
was unable to effect reduction ; and he has added the results of his ex- 
periments upon the cadaver, which confirm the statement already made 
by me. that this dislocation cannot take place without a rupture of the 
trapezoid ligament. 

Prognosis. — It is impossible for me to say what has been the precise 
result in all the cases which I have seen, but my notes furnish only two 
cases of perfect retention after a complete dislocation at this point. One 



Fig. 269. 



Fig. 270. 





Dislocation of the acromial end of the 
clavicle upwards. 



Dislocation of the acromial end of the 
clavicle upwards and outwards. 



of these. David Thomas, aged about twenty-five years, fell sideways upon 
tin- ground, striking upon the extremity, and, as he thinks, a little upon 
the top of the shoulder. The clavicle was dislocated upwards and out- 
wards, bo that it overlapped the acromion process half an inch. It was 
easily replaced, and having applied my own apparatus for broken collar- 
Lone-, with the addition of a band across the shoulder and under the 
elbow to keep the clavicle down, I succeeded in retaining the bone in 
place. This dressing was continued until the forty-second day, when, 
on being removed, the clavicle was seen to be closely confined upon its 
articulation : and after ;i lapse of two years it still retains its position so 
completely that no difference can be detected between the opposite 
articulations. 

In the case of Moran, already mentioned, whose clavicle overlapped 
the acromion process three-quarters of an inch, and who threw off the 
dressings at the end of three days, the same degree of displacement ex- 



1 Nicaiae, The Lancet, Oct. 14, 1*70, vol. 2. p. 585. 



678 DISLOQATIONS OF THE CLAVICLE. 

isted at the cud of two years; the scapular end of the clavicle moving 
freely in every direction under the skin according as the arm was moved. 
In lifting, he Bays, the strength of his arm is undiminished until he 
raise- the weight nearly to a level with his shoulders, and from this 
point upwards he can lift but little. For a laboring man it amounts to 
a serious maiming. I have seen the same loss of power in the arm to 
raise bodies above the head in at least two or three of the examples of 
less complete dislocation, continuing after the lapse of several years; but 
in the majority of eases, although the bone does not remain reduced, 
the patients have recovered eventually the complete use of the arm in 
whatever position it may be placed. 

The ease to which I have already referred as having been caused by 
a holt thrust upwards under the clavicle, will furnish the best illustration 
of this general principle. James O'Brien, 1st U. S. Artillery, was 
injured in September, 1862, by being run over by a horse-car. A bolt, 
three-quarters of an inch in diameter, was driven through the skin on 
the anterior margin of the left axilla, breaking the first rib, severing the 
coraco-clavicular ligaments, and forcing the clavicle upwards from its 
socket. No attempt at reduction was ever made. When seen by me 
one year after the accident, the outer end of the clavicle was lifted 
directly up two inches from the acromion process, to which it was united 
only by a long and slender ligament. He was not conscious of any loss 
of power or limitation of motion in the injured arm. At my request, 
my son, then in the U. S. service, instituted a series of experiments to 
test the relative strength of the two arms, and with the following result : 
First with the right arm, and then with the left, he lifted from the 
ground fifty-six pounds and three ounces, and sustained this weight above 
his head thirty seconds, with his arms fully extended. With his right 
arm extended at full length, at right angles with his body, he sustained 
twenty-five pounds for fifteen seconds. With the left arm he sustained 
the same weight, in the same position, seventeen seconds. 1 

Treatment. — When the bone simply rises upon its socket, the reduc- 
tion is always easily aeeomplished by pressing firmly upon its extremity 
with the fingers; but if, at the same time, it has been carried outwards, 
or outwards and backwards, the reduction is only accomplished by 
pulling the shoulders backwards, or by placing a pad in the axilla, using 
the arm as a lever, or by lifting the arm by the elbow and at the same 
time pressing the clavicle down ; and it will sometimes require the appli- 
cation of all or several of these procedures at the^ame moment. In some 
cases the complete reduction lias only been eifecteel when the patient has 
been brought under the influence of an anaesthetic. 

A- to the maintenance of the bone in its socket for a length of time 
sufficient to insure a firm and close union of the torn ligaments and cap- 
sule, this a\ i 11 be found always more difficult, and, in a great majority of 
cases, absolutely impossible. Nearly all surgeons who have written 
upon tlii< subject have made the same observation; and if occasionally a 
tew apparatus in the bands of a clever surgeon has seemed to promise 
better results, the same apparatus in the hands of other equally clever 

1 Amer. Med. Times, Oct. 24, 1803. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 679 

surgeons, and under circumstances equally favorable, has been found 
almost constantly to fail : and we have been compelled again to exercise 
anew our ingenuity, and to seek for new resources, or to abandon the 
effort in despair. 

Dr. Folts. of Boston, believed that he had found in Bartlett's appa- 
ratus for broken clavicles, modified by the application of a shoulder- 
strap, the infallible remedy for this one of the many sad defects in our 
art. The most important part of this dressing, according to Dr. Folts, 
is the compress placed upon the upper and outer end of the clavicle, and 
the bandage or strap passed over the compress and under the point of 
the elbow. 1 

Dr. Folts is no doubt correct in regarding this strap as an important 
if not the essential part of the apparatus ; and it is surprising that by 
Sir Astley Cooper, as well as by many other experienced surgeons, its 
value should have been overlooked. The chief obstacle to the retention 
of the bone in place is the powerful action of the trapezius, which con- 
stantly tends to elevate the outer end of the bone. In some measure 
this may be overcome by elevating very forcibly the shoulder, or by in- 
clining the head, but both of these positions are extremely fatiguing, and 
will not be long endured. The bandage or strap, adjusted in the manner 
which Dr. Folts has recommended, is the only means of counteracting 
the action of the trapezius, upon which any substantial reliance can be 
placed : but the principle has long been understood and practised upon. 
Brasdor's tourniquet, or Petits, secured by a strap brought under the 
point of the elbow. Boyer's double shoulder-straps, and Desault's third 
bandage, all aimed at the accomplishment of the same purpose ; yet 
Boyer and Desault found all these contrivances fail in a majority of 
Mayor employed a dressing constructed with a strap to buckle 
over the dislocated clavicle ; but Nelaton has seen this apparatus fail 
also, when applied in his own wards. 

The experience of Dr. Folts at the time of his report did not extend 
beyond three cases, and the apparatus had been completely successful in 
only two of the threfe. My own experience is sufficient to show that it 
will be found occasionally, but by no means constantly, successful. I 
have already mentioned two cases in which I succeeded perfectly by 
this mode, but in several others which seemed equally favorable I have 
met with partial or complete failures. 

The source of error, generally, on the part of those who think that 
they have devised an apparatus, or a method by which they can always 

_ ncrally succeed in holding the bone in place until the ligament- are 
reconstructed, i-. first, that they have not sufficiently noted how slight 
is the elevation, or projection, in a large majority of cases, before any 
dressing i- applied, so that finding eventually very little projection, they 
call it perfect : second, that they examine the shoulder, to determine 
whether the restoration i< complete, too soon after the apparel is re- 
moved, when a very slight remaining effusion into, and induration of the 
adjacent tissues, render it impossible t<» say what has been accomplished; 
and third, they have sometimes had under treatment too small a number 

1 Folts, Boston Med. and Burg. Journ., vol. liii. p. 269. 



680 



DISLOCATIONS OF THE CLAVICLE. 



of cases to entitle them to form a just conclusion as to the general value 
of their method of treatment. 

The practical difficulties are, the sensibility and consequent inability 
sometimes of the point of the elbow to bear the requisite pressure, and 
the even greater sensibility of the skin over the top of the clavicle ; the 
tendency of the bandage to slide off from the shoulder, and also to become 
displaced from the end of the elbow ; the gradual relaxation of the band- 
ageSj which, when existing even in the most inconsiderable degree, is 
sufficient sometimes to allow the bone to slip out from its shallow socket ; 
the impossibility of fixing the scapula, upon whose immobility as well as 
upon the immobility of the clavicle the retention depends ; and, finally, 
the great length of time requisite to unite firmly the ligaments, if indeed 
they ever again become actually united. 

The band can be prevented in some measure from sliding off from the 
clavicle by a counter-band attached to a collar upon the opposite shoulder, 
but not without causing some pain, and giving rise to excoriations gen- 
erally in the opposite axilla ; and, in a degree, all the other difficulties 

may be met by patience and in- 
Fig. 271. genuity, but unfortunately the 

smallest failure in any one of 
these numerous indications in- 
sures a defeart. 

The axillary pad employed as 
a fulcrum upon which extension 
may be made is equally as dan- 
gerous here as in fractures, and 
I do not think it ought ever to 
be used for this purpose, but only 
as a means of moderate support 
and retention; indeed it would 
be well, perhaps, if it were dis- 
carded altogether. 

The case of Mr. B., already 
quoted, with a dislocation out- 
wards and backwards, affords not 
only an illustration of the in- 
efficiency of either the shoulder- 
strap or the axillary pad in cer- 
tain cases, but also, it seems to 
me, of the mischief which may 
result from their too diligent application; for I cannot persuade myself 
but that most of the maiming in this case was due to the apparatus 
rather than to the original accident. 

This gentleman was injured on the 10th of November, 1855. A sling 
with an axillary pad and bandages was immediately applied. I saw him 
on the seventeenth day. The displacement was then such as I have de- 
scribed, hut I did not observe any paralysis or emaciation of the limb. 
Saving noticed that the clavicle fell into its socket when he lay upon his 
back in bed. nt my suggestion all the dressings except the sling were 
removed, and the patient laid upon his back in bed, with instructions to 




Mayor*! apparatus fur dislocated clavicle. 
('•Triangle cubito-bis-scapulaire.") 



OF THE ACROMIAL END OF CLAVICLE DOWNWARDS. 681 

continue in this position, if possible, until the cure was complete ; but 
after a few days I received a communication from his physician, stating 
that, owing to a troublesome cough, he had found it impossible to main- 
tain this position. His residence was forty or fifty miles from town, and 
I sent him one of my dressings for broken collar-bones, with instructions 
as to its use : directing especially that a shoulder-strap should be used 
to keep the clavicle down. 

The dressing was applied and continued six weeks, and on being re- 
moved, the elbow, wrist, and finger-joints were found to be stiff. The 
whole arm was emaciated and almost powerless. One year later there 
was no improvement in the condition of the arm; every joint from the 
shoulder down was almost completely anchylosed, the muscles were 
greatly wasted, and the hand trembled constantly. 

These results, it seems to me, were due to too long and too tight band- 
aging of the arm. and especially to the pressure of the axillary pad. I 
do not state this positively, but this is my belief. 

Is it worth while, then, to incur the dangers of too long confinement 
and of excessive bandaging for the purpose of attaining the always un- 
certain result of maintaining the bone in its socket ? We certainly may 
be permitted to make the attempt within certain reasonable limits ; and 
especially if the patient is a female, and the avoidance of deformity is a 
point of serious consideration ; but never without keeping constantly in 
mind the possibility of a permanent anchylosis and paralysis of the limb. 

Dr. Gross says he first suggested the use of strong silver wire to keep 
the parts in place, and this suggestion was carried into effect by Dr. 
Cooper, of San Francisco, and by Dr. Hodgen, of St. Louis l 

Dr. Hodgen informs me under date of January 29, 1881, that he has 
made the operation twice, and that both resulted well, the parts being 
kept well in position : but that with his present experience he would not 
repeat the operation, except in cases of very great displacement. In 
this latter opinion, as to the circumstances under which alone the opera- 
tion would be justifiable. I fully concur : and even in such a case its 
propriety is questionable. 

(b) Dislocations of the Acromial Exd of the Clavicle 
Downwards. 

This form of dislocation is exceedingly rare, only five well-authenti- 
cated cases in'- known to me as having been placed upon record, one of 
whir-]) was -<•<■]! and dissected by Melle in 1765, the second was met with 
by Floury in 181 6, and the third is described by Tournel. 

Dr. Walter ]). Chase, of Brooklyn, N. Y., has reported a case in a 

- y.ar- old. who fell headforemost Aug. 15, 1877, twelve or fifteen 

striking the top of his shoulder upon the round of* a ladder. The 

patient was thin, and the exact position of the clavicle was easily traced. 

The axis of the bone was changed, carrying the acromial end downwards 

and a little backwards. The anterior portion «»}' the shoulder was flat- 

1 Hodgen, Ame I Sci., April, 1876, p. 452; [bid. April, 1861. p, 389. 



682 DISLOCATIONS OF THE* CLAVICLE. 

tened, and the acromion process was very prominent. He could move 
the arm slightly when it hung by his side. 

The boy was anaesthetized, and the reduction easily effected "by 
throwing the Bhoulder outwards and backwards, while at the same time 
I grasped the clavicle in its outer third with the extremities of my fingers 
and thumb, and carried it upwards and forwards into its normal position. 
There was no subsequent tendency to displacement.'" 1 

Dr. Allen 2 has seen a case of dislocation downwards in a boy, set. 16, 
who was in good health and vigorous. The dislocation had been caused 
while splitting wood with an axe, the arm being elevated and carried 
slightly outwards. There ensued disturbance of motion and of sensi- 
bility in the arm. which Dr. Allen ascribed to pressure upon the nerves. 
Under the use of electricity these disturbances disappeared, and the cure 
was complete. 

Cause. — So far as I can ascertain, except in the case reported by 
Dr. Allen, it has been produced by a force which has acted directly upon 
the top of the clavicle. In the case mentioned by Tournel, a horse had 
trod upon the shoulder; and in the example recorded by Melle, the 
accident occurred in a child six years old, from an attempt to support a 
great weight upon the top of the collar-bone. In this last example the 
humerus was dislocated also, and both dislocations had remained unre- 
duced many years when the patient was seen by Melle. 

This force acting directly upon the top of the clavicle would fail to 
dislocate the bone, except by first breaking down the coracoid process, 
if it did not happen sometimes that at the same moment the lower angle 
of the scapula was thrown outwards, in such a manner as to depress 
slightly the coracoid process, and thus to permit the outer end of the 
clavicle to fall below the level of the acromion process. 

Symptom* and Pathology. — This dislocation, whether it has been pro- 
duced artificially upon the dead subject, or accidentally upon the living, 
has always been found to be accompanied with a complete rupture of the 
acromioclavicular ligaments not only, but also of the coraco-acromial and 
com co-clavicular ligaments ; the outer extremity of the bone resting be- 
tween the acromion process and the capsule of the shoulder-joint, and a 
little posterior to the articulating facet which originally received the 
clavicle. 

The superior angle of the scapula approaches the body slightly, and 
its inferior angle is thrown outwards. A marked depression exists at 
the point of dislocation, accompanied with a sharp pain, increased espe- 
cially when an attempt is made to move the arm. The patient is unable 
to lift the arm voluntarily, but it can be moved pretty freely in the 
direction forwards and backwards by the hands of the surgeon; abduc- 
tion ig much more difficult. 

Treatment. — Reduction is easily accomplished. At least, in all of the 
examples presented in the living subject, and referred to above, where the 
attempt was made, it was effected promptly by drawing the shoulders out- 
warde and backwards: nor has it been found anymore difficult to maintain 

1 Chase, Transactions Med. Soc. State of New York, 1879, p. 174. 

2 J. L. Allen, Med. Record, Feb. 19, 1881. 



DISLOCATIONS OF ACROMIAL END. 683 

it in position when once replaced. When the scapula is restored to its nat- 
ural position, and its lower angle approaches again the side of the body, a 
reallocation becomes impossible ; since the coracoid process now effectually 
prevents that descent of the clavicle upon which its displacement always 
depends. It is only necessary, therefore, to secure the scapula at its 
base and lower angle snugly to the body, by a broad band and compress, 
and all the indications of treatment are completely fulfilled. 

(c) Dislocations of the Acromial End of the Clavicle under 

THE CORACOID PROCESS. 

Pinjou met with one example of this singular dislocation, 1 and Gode- 
mer, of Mayenne, has recorded five more, 2 and these constitute the whole 
number which are at this day known to science. 

Cause. — Age and a consequent relaxation of the ligaments seem to 
constitute a predisposing cause, since of the six recorded examples four 
were between the ages of sixty-seven and seventy-one, and the other two 
were adults. In all the cases, also, the dislocations were the results of 
falls upon the shoulder. 

The symptoms which have been said to characterize this accident are 
pain and a very marked depression at the point of displacement, with a 
corresponding projection of the acromion and coracoid processes; a rapid 
inclination outwards and downwards of the line of the clavicle, its outer 
extremity being felt in the axilla; the corresponding shoulder depressed 
and inclined forwards ; freedom of motion in all directions except inwards 
and upwards; the lower angle of the scapula thrown outwards and back- 
wards : to which Morel-Lavallee has added an actual increase of space 
between the acromion process and the sternum. 

Treatment. — Godemer reduced all the examples which came under his 
notice easily, by directing an assistant to pull the arm backwards and 
outwards while he himself seized upon the clavicle with his fingers, and 
disengaged it from under the process; but Pinjou, after many efforts by 
the same method, failed completely, and the patient having left him, the 
clavicle was reduced the next day by an empiric. Vidal (de Cassis) 
recommends that instead of pulling the arm outwards, by which proced- 
ure the pectoralis major is made to antagonize the surgeon, the elbow 
shall be brought down to the side, and kept there by the left hand, while 
the right hand, placed in the axilla, shall pull the upper end of the 
humerus outwards, converting the arm into a lever of the third kind. 
This process, I confess, seems to be much the most rational. 

Filially, having given the history of these cases as they have been 
reported, the author will scarcely have performed his duty as a faithful 
writer if he does not state frankly that he entertains a suspicion that both 
the gentlemen who have reported these curious examples have entertained 
us with fabulous or imaginary stories: and especially do these suspicions 
upon the cases reported by Godemer, who in five years saw five 
. each presenting throughout the same class of symptoms, the same 

1 Pinjou. Journ. de Med", de Lyon, Juillet, 1842, from Vidal (de Cassis). 

•il dee travaux do la Soc. M<'-<\ d'Indreel Loire, 1848, from Vidal. 



1184 DISLOCATIONS OF THE CLAVICLE. 

facility of reduction, accomplished by the same moans, and always with 
the same perfect result. 

If to these singular coincidences we add the fact that only one other 
Burgeon has ever claimed to have met with the accident, and if we notice 
the actual anatomical difficulties which stand in the way of its occur- 
rence, such especially as the complete occlusion of the subcoracoidean 
space by the tendons and muscles which pass from its extremity toward 
the chest and arm, we shall find a fair apology for some degree of scep- 
ticism. 

(d) Dislocations of the Claytcle at both Ends, simultaneously. 

On the 26th of January, 1863, Dr. North, of Brooklyn, N. Y., was 
called to see a lad fourteen years of age, who had been thrown with vio- 
lence backwards from a stool upon which he was sitting, striking the 
back of his left shoulder against the floor. Dr. North found him suffer- 
ing severely from pain, and with some difficulty of breathing. The 
shoulder was depressed and thrown forwards. The sternal end of the 
clavicle, turned forwards, formed an abrupt, rounded prominence; the 
acromial end, turned forwards also, presented its longest diameter toward 
the surface, and rested above the acromion process ; while the central 
portion seemed depressed or thrown back, an appearance which was 
caused by the rotation of the clavicle upon its axis. 

Reduction was accomplished by throwing the shoulders forcibly back- 
wards, and at the same time pressing with the thumbs upon the two 
extremities in such a manner as to reverse the rotation, as follows: press- 
ing at the acromial end backwards and downwards, and at the sternal 
end backwards and upwards. The restoration was complete, and the 
bones were retained in place by compresses and adhesive plaster, with 
the aid of Day's "neck yoke." At the end of three weeks the dress- 
ings were removed; and when last seen by his surgeon '"there was but 
little, if any trace of the accident remaining." It is the opinion of Dr. 
North that the rotation was caused by the action of the pectoralis major 
and deltoid after the dislocation took place. 1 

Erich-en says that Kicherand and Morel-Lavallee have each reported 
one example of double dislocation of the clavicle. Another example 
has been reported by Dr. Col. 2 

In a case observed by Lund, 3 and reported by Jones, the patient, a 
man 32 years of age, was struck on the posterior portion of the right 
shoulder, dislocating the sternal end of the right clavicle forwards, and 
tin- acromial extremity upwards and backwards. It was found impos- 
sible to reduce tlie dislocation except under the influence of an anaes- 
thetic In a lew days the functions of the arm were completely restored. 

Rombeau' met with a similar case, which is reported by Gros. The 
dislocation, having beeu first recognized several days after the accident, 
was reduced and maintained by an apparatus similar to that of Desault, 
which remained in place five weeks. Ultimately the patient recovered 

1 X. L. North. M.J>.. New York Bled. Record, April 16.1866. 

2 Col, Gaz. dee Hdpitaux, L872,p. 893. 

3 Lund, Brit. Med. Journ., 1874, No. 682, p, 106. 

4 Rombeau, Bull. (u'n. de Therapeutique, 1874, vol. lxxxvi. p. 537. 



DISLOCATIONS OF THE SHOULDER. 685 

with slight remaining deformity, and with the motions of the arm com- 
pletely restored. 

Dr. Stanley Haynes. of Malvern Link, has reported the only remain- 
ing case of which I have been able to find a record. 

"A girl, aged 13. rapidly growing, of lax tissues, and of a consump- 
tive family, but who had always had good health, while washing the 
back of her neck with her left hand, one morning in September, felt 
something give away in the shoulder of the same side. I found disloca- 
tion forwards of the sternal end of the clavicle and partial dislocation 
upwards of the acromial one. There was very little pain. Both ex- 
tremities of the bone were easily replaced by drawing the shoulder 
backwards and downwards, but the double deformity was reproduced 
immediately the shoulder was liberated. A pad was applied under a 
figure-of-8 bandage over the sternal end. and the arm was placed in a 
sling as a temporary measure. To a strap, fastening round the chest. 
a strap bearing a truss-pad was attached in such a manner that the pad 
kept the sternal end of the clavicle reduced, the other end of the strap 
passing over the shoulder and diagonally across the back to the hori- 
zontal strap : the wearing of a sling kept the acromial end in its natural 
position. The patient soon afterwards returned to school at a distance. 
She is now at home, and I have found the sling has been discontinued 
-«;«me time : that the straps have stretched and are useless ; and that the 
ends of the bone are as mobile as. but not more than, they were when I 
first saw the patient, but that the sternal end does not become dislocated 
unless the arm is raised, when it nearlv alwavs starts forwards." 1 



CHAPTER VII. 

DISLOCATIONS OF THE SHOULDER SCAPULO-HOIEEAL. 

Ownra to the great exposure and the peculiar anatomical structure 
of the shoulder-joint, its structure having reference mainly to freedom 
of motion rather than to firmness and security in the articulation, dislo- 
- "f the humerus are very common. 
My private and hospital records furnish me with 117 cases of disloca- 
tion of the shoulder, seen and recorded by myself. Of these, 11 were 
- ibglenoid, S3 as subcoracoid, a very small proportion as 
. ivicular. '1 - - nous, and the remainder were not accurately 

- tied. 
Writers have not been agreed as to the precise anatomical relations 
of tli-- - tions, 9 1 the nomenclature. Velpeau, Malgaigne, 

Vidal (de * ssis), S . lid Sir Astley Cooper have each adopted ex- 
planations and classifications peculiar to themselves. With the arrange- 
ment established by this latter a English and American students 

1 T: Journal. Jan. 27. 1872. 



»'» S 'J DISLOCATIONS OF THE SHOULDER. 

are the most familiar: and believing that it is more simple, and quite as 
appropriate as either of the others. 1 shall adopt it as the basis of my 
own descriptions. 

1 shall have occasion, however, to dissent from the opinions and 
teachings of this distinguished surgeon, as to the exact seat and rela- 
tions of the head of the humerus in some of these dislocations. 

According to Sir Astley Cooper, there are three complete dislocations 
of the shoulder : namely, downwards, forwards, and backwards. 

The so-called " swpra-coracoid " dislocation, without a fracture of the 
coracoid or acromion processes, the possibility of which has been denied 
by Boyer, but examples of which are declared to have been seen by 
Malgaigne, Holmes, Hewitt, have now sufficient affirmative testimony to 
justify me in devoting a section to its consideration. 

§ 1. Dislocations of the Shoulder Downwards (Subglenoid). 

This is usually called a dislocation into the axilla ; the head of the 
bone resting rather upon the inner side of the inferior border of the 
scapula, near the base of that triangular surface which is found below 
the glenoid fossa. 

Since in both the other complete dislocations of the shoulder, the head 
of the humerus, in order to escape from its socket, must be made to de- 
scend more or less downwards, I shall regard this dislocation as the 
type of all the others, and shall make it the subject of especial consider- 
ation as well as of reference ivhen speaking of the other forms of dis- 
location. 

Causes. — The most frequent cause of this accident is a blow received 
directly upon the upper end and outer surface of the humerus. I have 
found the arm dislocated into the axilla by this cause thirty-one times ; 
five times by a fall upon the extended hand : three times by a fall upon 
the elbow ; and in these latter cases the arm was probably carried away 
from the body at the moment of the receipt of the injury. 

In all the above examples the shoulder has been dislocated by the 
simple force of the blow, or with only slight aid from muscular action; 
but in a considerable number of cases the bone is displaced almost 
wholly by the action of the muscles, the arm having been previously 
violently abducted : and perhaps in some cases the capsule being torn 
before the resistance of the overstrained muscles has accomplished the 
displacement. Thus, in three instances I have known the dislocation 
to result from holding on to the reins after being thrown from a car- 
riage : in two cases the patients have fallen through a hatchway and been 
caughl and suspended by the arms ; once a woman met with this accident 
by holding on to a pump-handle when she had slipped and fallen upon 
th«- Lee. A few years since I examined the arm of a Swiss woman. Maria 
Norregan, who was then sixty-five years old, and whose humerus had 
hccii dislocated into the axilla seventeen years before, where it still re- 
mained. Her own account of the accident was, that she was returning 
from the Jura Mountains, near Neufchatel, with a load of hay upon her 
head. She had carried it a long way with her hands held upwards, 
without once stopping to rest, and when at length she threw down the 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 687 

load at her door, the right shoulder was disloeated. The arm soon be- 
came very painful, and swollen to the fingers' ends : but she was too 
remote from, and too poor to employ, a surgeon. A tailor, who used to 
do the minor surgery of the neighborhood, bled her three or four times, 
but the dislocation was not recognized until many months after. 

A Mrs. Hunn informed me that when she was twenty-two Years old 
she had a convulsion, and that her attendants in trying to hold her 
upon her bed, actually pulled the shoulder out of joint. After the first 
accident the dislocation was not repeated for four years, but since then 
it had occurred from very slight causes many times. She was in the 
habit of reducing it herself by placing a ball in the axilla and using the 
arm as a lever. 

Dr. Scatliff. of Brighton, 1 Coombs, of Castle Cary, 2 and others have 
published examples of this dislocation, caused by epileptic convulsions. 
I have myself seen such examples. 

Dr. Lehman reports the case of a sailor on board an American brig, 
who was subject to a dislocation into the axilla from very slight causes, 
and especially if he bent his body far over to raise anything. He could 
also, by pulling horizontally, remove the head of the bone from its 
socket. It was reduced easily, and he experienced no pain either in the 
reduction or dislocation, nor. indeed, during the displacement. 3 

Pathology. — In this accident the head of the bone is made to press 
against the capsule below and immediately in front of the long head of 
the triceps, until the capsule gives way, and continuing to descend in 
the same direction it is finally arrested by the triangular surface of the 
inferior edge of the scapula immediately below the glenoid fossa. Owing 
to the pressure of the tendon of the triceps behind, it occupies a position 
also a little in advance of the centre of this triangle, or rather upon its 
anterior edge, so that it rests more or less upon the belly of the sub- 
Bcapularis muscle. 

The capsule is generally torn quite extensively, especially below and 
in front : and the tendon of the long head of the biceps may be broken 
asunder, or detached completely from its insertion: the supra-spinatus 
muscle is stretched or lacerated : the infra-spinatus, subscapularis, and 
coraco-brachialis are put upon the stretch ; the subscapularis being also 
sometimes completely torn from its attachment to the head of the humerus, 
and in either case, whether torn or merely compressed and stretched, the 
circumflex nerve, which runs along its lower margin, is subject to severe 
injury: the deltoid muscle is also placed in a condition of extreme ten- 
: while the teres major and minor in this respect are subjected to 
but little change. 

In some cases a portion or the whole of the greater tuberosity is com- 
pletely detached, and the fragment displaced by the action of the muscles 
inserted into it. 

In on.- ease tin- axillary artery has been ruptured. The patient had 
been thrown down by a runaway horse, and was taken t<> Jervis Street 

tliff, T1k ; Lancet, 1878, vol. i. p. 31. 
3 Lehman, irn. Med. Sci., vol. i. p. 242, 1828. 



DISLOCATIONS OF THE SHOULDER. 

Hospital, London. On the tenth day Surgeon O'Reily tied the sub- 
clavian artery, and the patient recovered after the loss of two fingers 
from erysipelas and gangrene. 1 

With more or less rapidity, after the occurrence of the dislocation, if 
the bone remains unreduced, various changes take place in the anatomi- 
cal relations and structure of the parts. The following is a brief account 
of the condition in which the parts were found in the case of an old man, 
whose history is unknown. The dissection was made by my assistant, 



Fig. :272. 



Fig. 




Dislocation of the shoulder downwards into 
the axilla. (Subglenoid.) 



Dislocation downwards, showing the untorn 
portion of the capsular ligament. (Gunn.) 



Dr. Frank Deems, at the Bellevue dead-house. The head of the hume- 
rus was in front of the socket, below, but not in contact with, the cora- 
coid process, lying upon the anterior surface of the neck of the scapula. 
A new socket was formed in the bone at this point, mostly cartilaginous, 
and a fibrous capsule inclosed the head of the humerus. The margins 
of the old socket were removed, and the socket was filled with fibrous 
tissue. The axillary nerves and artery were not injured or compressed. 
The biceps tendon was not torn. All the muscles about the shoulder 
were atrophied. 

Symptom*, — A palpable depression immediately under the extremity 
of the acromion process, more distinct in children, in very old and in 
thin people, than in adults of middle life or than in fat or muscular 
people, but never absent completely, unless the shoulder is very much 
swollen : the elbow carried out from the body three or four inches, 
sometimes a little backwards, and the line of its axis directed toward 
the axilla : the outer surface of the arm presenting two planes inclined 

1 Todd's Cyclop. Anat. and Surg., p. 616: Holmes's Surg., vol. ii. p. 827. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 689 



toward each other, and meeting at the point of insertion of the deltoid 
muscle : the head of the humerus felt in the axilla, particularly when 
the elbow is carried away from the body ; numbness of the arm, accom- 
panied generally with pain, especially when any attempt is made to 
press the elbow against the side ; rigidity with inability to move the 
arm freely in any direction, but especially inwards ; allowing, however, 
of pretty free passive motion, but not permitting the elbow to touch the 
body without great pain, which pain is occasioned mostly by the pressure 
of the humerus upon the axillary plexus ; under no circumstances can 
the hand be placed upon the opposite shoulder while at the same moment 

Fig. 274. 




Dislocation of the shoulder downwards into the axilla. (Subglenoid.) 

the elbow touches the thorax ; the head of the patient, and sometimes 
the whole body, inclined toward the injured arm; the arm lengthened 
from half an inch to an inch ; a chafing or friction sound is not unfre- 
quently present, especially if the bone has been some days dislocated; 
but Mr. Lawrence mentions a case in which there was a distinct crepitus, 
yet there was no fracture; Dr. Hays saw a similar case in Wills Hos- 
pital, Philadelphia, in a woman sixty years old, whose arm had been 
dislocated forwards eight weeks. 1 Other surgeons have related like 
examples, but it is probable that in all these cases there has been an 
exposure of the bone at or near the edge of the glenoid fossa, by the 
partial detachment of its ligamentous margin, or some portion of the 
head has become divested *»f* its cartilaginous covering. (For a more 
complete differentia] diagnosis, see chapter on Fractures of the Humerus.) 
Decisive ;i- these signs usually are of the true nature of the accident, 

Lawrence. II;.;.-. A:,:. Journ. lied. Sci., vol. xxiv. p. 230. May, 1839. 
44 



690 DISLOCATIONS OF THE SHOULDER. 

oases will every now and then occur in which the diagnosis will be 
attended with great difficulty, and especially if a few hours have been 
permitted to elapse since the occurrence of the injury, so that consider- 
able eifusions of blood and of lymph may have taken place; while at a 
still later period, when the swelling has subsided, the diagnosis again 
becomes easy. -At this hitter period," says Sir xlstley Cooper, "it is 
that surgeons of the metropolis are usually consulted; and if we detect 
a dislocation which has been overlooked, it is our duty in candor to state 
to the patient that the difficulty of detecting the nature of the accident is 
exceedingly diminished by the cessation of inflammation, and the absence 
of tumefaction." 

In a rapid review of the cases of dislocation of the shoulder which 
have come under my notice, and of which I have taken pains to make a 
record, I find thirteen subglenoid and ten subcoracoid dislocations which 
were not recognized as such by the surgeons first called. Some were 
mistaken for fractures, and some were called contusions or sprains. And 
among the surgeons who fell into these errors are some of our oldest and 
most experienced hospital surgeons. I have, however, seen many more 
unrecognized and unreduced dislocations of the shoulder, than are men- 
tioned above ; but the frequency with which I have met them must not 
be regarded as representing the usual ratio of these errors of diagnosis 
in general practice, inasmuch as the majority of them were examples in 
which the patients or the surgeons have consulted me for advice. 

It is due to science, if not to myself, to say that it has never happened 
to me to have seen a case of dislocation of the shoulder which I have not 
recognized. Although, therefore, I am prepared to admit the justness 
of the observations made by Sir Astley Cooper, I think that errors in 
diagnosis are often due to carelessness, or to a lack of experience, or to 
an insufficient study of the well-established rules of diagnosis. Upon 
this subject I have already spoken very fully in the chapter on Fractures 
of the Humerus ; and from the examples and opinions which I have there 
presented it will be inferred that it is much more common to mistake a 
fracture for a dislocation, than a dislocation for a fracture, an observa- 
tion which is equally as applicable to dislocations forwards as to the form 
of dislocation now under consideration. 

• Prognosis. — If the force which displaced the bone w r as not great, or 
if the shoulder-joint has not suffered any injury from the accident itself 
beyond the mere rupture of the capsule and a moderate straining of the 
muscles, and if the dislocation has been early and easily reduced, the 
patient is immediately after the reduction able to move the arm freely in 
;ill directions; \<ty little swelling follows, and in a short time a perfect 
restoration of all the functions of the limb is accomplished. 

It cannot, however, always be inferred from the degree of violence 
employed in tlie production of the dislocation, nor from the absence or 
presence of swelling, how much injury the tendons, muscles, and nerves 
have suffered, since the same causes produce greater lesions in one per- 
son than in another, and the amount of swelling may depend upon the 
accidental rupture of an unimportant bloodvessel, or upon some pecu- 
liarity in the constitution of the patient predisposing to serous, fibrous, or 
sanguineous effusion-. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 691 

To whatever cause we may find occasion to attribute the result, it will 
nevertheless be observed that, in a great majority of cases, the limb is 
not restored to all its original strength and freedom of motion until after 
the lapse of some months ; and the shoulder does not resume its perfect 
form and symmetry until a much later period; occasional pains, espe- 
cially after exercise of the muscles, and in certain conditions of the 
weather, are present also at irregular intervals and for indefinite periods 
of time. Opposite and more favorable terminations must be regarded as 
exceptions to the rule. 

Where the reduction has been made within a few hours, I have found 
the shoulder affected with muscular anchylosis with more or less weak- 
ness of the arm after a lapse of from a few days to one or two years. 

A laborer, aet. 41, had dislocated his right shoulder into the axilla. 
Dr. H., an intelligent young surgeon, reduced the bone easily with his 
hands alone, while the patient was still unconscious from the shock of 
the injury. After six weeks he called upon me, accompanied by his 
surgeon, thinking that it was not property reduced because the arm was 
still painful, and he could not move it freely. The bone was, however, 
well in its socket. One year later I examined this man, and found some 
anchylosis remaining in his shoulder-joint. 

James Rogers, set. 39, fell while running, and struck upon his right 
shoulder. Dr. Eastman, Professor of Anatomy in the Buffalo Medical 
College, reduced the dislocation four hours after the occurrence, in the 
following manner : The patient being seated in a chair, Dr. Eastman 
placed his knee in the axilla and manipulated, while one assistant sup- 
ported the acromion process, and another pulled downwards upon the 
forearm. The time occupied in the reduction was about two minutes, 
and the bone finally resumed its position with a snap audible to all the 
persons in the room. For some months after, and at the period when I 
was invited to see him, the muscles about the shoulder were rigid, and 
the motions of the joint embarrassed; but at the end of two years, Dr. 
Eastman informed me that the joint had become free and the arm as 
useful as before, except that he could not throw a stone. 

In another case, a gentleman residing in an adjoining county, set. 42, 
was thrown from his carriage, falling forwards upon his hands. The 
dislocation was reduced promptly, by placing the heel in the axilla, and 
within fifteen minutes after it had occurred. Three months after this the 
patient consulted me on account of the immobility of the shoulder-joint, 
and because several surgeons had expressed a doubt wdiether it was 
properly reduced. The anchylosis was then so complete that the humerus 
could not be moved separately from the scapula, but there was no dis- 
placement. This gentleman again '-ailed upon me at the end of four 
years, and I then found the arm nearly restored to its original condition, 
but it was not quite so strong as before. He experienced also "curious " 
sensations in In- arm and hand occasionally. The anchylosis had con- 
tinued with very little improvement about two years, after which it had 
been gradually disappearing. 

I need scarcely say that in those examples in which the reduction of 
the bone has been delayed beyond a few hours, or for several days or 
weeks, the continuance of the anchylosis has been more persistent; but 



692 DISLOCATIONS OF THE SHOULDER. 

iii no case which has come under niy observation, unless the bone still 
remained unreduced, lias the anchylosis been permanent. For this reason 
1 am disposed to think that muscular, rather than fibrous or ligamentous 
anchylosis, is the cause, generally, of the immobility of the joint. I 
have certainly never in any instance met with a true bony anchylosis as 
a consequence of a shoulder dislocation. The anchylosis in question 
seems to be a result simply of laceration or more generally of a severe 
strain of the muscular fibres, resulting in inflammation and a contraction 
of these fibres ; and its occurrence in any particular case may therefore 
be justly attributable either to the position of the bone when it is dislo- 
cated, to the force of the blow which has produced the dislocation, or to 
the violence applied in the attempts at reduction. 

Paralysis and wasting of the muscles of the arm, either with or without 
muscular contraction and rigidity, are also observed in a certain number 
of cases. Especially has it been noticed that the deltoid muscle is liable 
to atrophy ; and in their attempts to explain the frequency of its occur- 
rence in this latter muscle, surgeons have generally referred to a probable 
rupture of the circumflex nerve, a circumstance which the autopsies show 
does occasionally take place ; or to a mere stretching of this nerve ; yet 
it is quite as fair to presume that in many cases it is due solely to the 
greater injury which the deltoid muscle has sustained by the unnatural 
position of the head of the bone during the continuance of the disloca- 
tion, for, with the exception of the supraspinatus, it is placed more upon 
the stretch than any other. Nor is it improbable that in some cases it 
is due to the mere force of the blow, which, having been directly upon 
the top of the shoulder, has contused the muscle. In short, any of the 
causes which may determine in the deltoid inflammation and consequent 
rigidity, must finally result in desuetude and consequent atrophy. 

In the case of an adult, P. Madden, who consulted me in June, 1874, 
there were slight atrophy and paralysis of the deltoid, and almost com- 
plete atrophy of the supraspinatus, with much anchylosis, due, I think, 
to prolonged efforts at reduction. 

In quite a number of cases my attention has been called to a remark- 
able fulness just in front of the head of the bone, which has continued 
sometimes for many months and even years after the reduction has been 
effected ; the patients having in several cases applied to me to know 
whether this did not indicate that the bone was not in its socket, espe- 
cially as it lias usually been attended with some stiffness in the joint. 
Not [infrequently I have been told that surgeons who had noticed this 
fulness, thought the bone was not reduced; and in one instance I am 
Informed that a jury returned a verdict against the surgeon, where there 
was no other evidence of malpractice than this fulness with some anchy- 
losis, but which, in the opinion of some medical gentlemen who testified, 
was conclusive evidence that the bone was not properly set. The decep- 
tion is also often the more complete from the fact that there may exist a 
corresponding depression underneath the acromion process, behind. 

These phenomena may be present where but little force has been used, 
either in the production of the dislocation or in its reduction. I have seen 
it in a girl only fourteen years of age, who had dislocated her left shoul- 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 693 

der into the axilla, by a fall upon a slippery side-walk. I reduced the 
bone, assisted by Dr. George Burwell, within half an hour after the 
accident. Dr. Burwell held upon the acromion process, while I lifted 
the arm to a right angle with the body, and pulled gently, and the re- 
duction was at once accomplished : but we immediately noticed that the 
head of the bone seemed to press forwards in the socket so as to resemble 
what Sir Astley Cooper has described as a partial forward dislocation. 
There was also a corresponding depression behind. Carrying the elbow 
back rendered the projection more decided, but bringing it forwards did 
not make it entirely disappear. 

In other instances where the deformity in question has been present. 
more force has been employed in the reduction. A man weighing two 
hundred pounds, forty-one years of age, residing at Bath, Steuben Co.. 
fell from a load of hay in May, 1853, striking upon the top and front of 
the left shoulder. It was immediately ascertained that he had dislocated 
his arm into the axilla, and broken his leg. A young surgeon attempted 
within a few minutes to reduce the dislocation, but failed; and about two 
hours later it was reduced by another surgeon, with the aid of chloro- 
form and Jarvis's adjuster. Four years after the accident this gentleman 
came to me accompanied by the surgeon who had made the reduction, in 
consequence of its having been intimated by some medical men that it 
was not properly reduced. The arm was not as strong as the other : 
some anchylosis existed at the shoulder-joint; but especially it was 
noticed that there remained a remarkable fulness in front, as if the head 
f »f the bone was pressed forwards. By no manipulation or position could 
this fulness be made to disappear, yet the bone was plainly enough in its 
-ucket. 

This phenomenon is probably due in some cases to a rupture of the 
supraspinatus muscle, and the consequent preponderating action of the 
antagonizing muscles, or to the extensive laceration of the capsule ; but 
in others. I imagine, to a rupture or possibly to a displacement of the 
1oijl p head of the biceps, a circumstance to which I shall more particu- 
larly allude under the subject of ''Partial Dislocations." 

Among the results of this dislocation must be placed a tendency to 

- ication, which, although it may not often be made manifest by its 
actual occurrence, owing perhaps to the prudence of the surgeon, yet it 

take place in a sufficient number of cases to establish its peculiar 
liability. Indeed, we need only consider how imperfect is the protection 

ist this accident, when once the capsule has been torn, to appreciate 
this observation. Examples of spontaneous dislocation, or of dislocation of 

- oulder from very trivial causes after it once has been dislocated, may 
be found in the experience of almost every surgeon. I have met with 

il persons who have had repeated dislocations from a slight cause, 
and in some instances where tin- patient- were subject to epilepsy the 
dislocations have occurred whenever the convulsions returned. 

A gentleman residing at Toronto, Canada West, had ;i dislocation of 
the right shoulder into the axilla when 1m- was quite a child, and the ac- 
cident was renewed when twenty-nine years old by tailing from ;i carriage 
foremost, with his right arm extended and uplifted. Sine- then. 



694 DISLOCATIONS OF THE SHOULDER. 

until he called upon me, a period of about six years, he has been con- 
stantly subject to the same dislocation ; and he cannot raise his arm high 
above his shoulders without producing a partial dislocation, the head of 
the humerus resting upon the outer margin of the lower and anterior edge 
of the glenoid fossa, but by rotating the arm .outwards it immediately 
resumes its place. I found the whole limb as fully developed, and he 
said it was quite as strong, as the opposite limb. 

I have already mentioned the case of Mrs. Hunn, whose arm had been 
dislocated more than twenty times during five years ; and I remember 
a. lad, Pat Dolan, aged nineteen years, whose left arm was dislocated by 
falling from the masthead of a vessel, and hanging by his hand. No 
attempt was made to reduce it until fourteen hours after the accident, at 
which time it was set by two German doctors, but not until they had 
pulled upon it three hours. Four months after, it was again dislocated 
by the slipping of an oar wdrile he was rowing a boat. A surgeon having 
failed this time to bring it into place, I succeeded readily, and without 
the aid of an anaesthetic, by raising the arm directly upwards in the 
line of the body, while my foot was pressed upon the top of the scapula. 
Many other similar examples have come under my notice. 

I have referred more than once to the occasional difficulty of diag- 
nosis in this as w r ell as in many other shoulder accidents. Other writers 
have mentioned many examples of unreduced dislocations of the shoulder, 
for which surgeons of skill and experience were responsible. I have 
myself, as before stated, met with these cases quite often. For example, 
I will mention here that I have seen two dislocations of the humerus into 
the axilla, both of which had been seen and examined by New York hos- 
pital surgeons within a few hours after the receipt of the injury, but the 
nature of the accident had not been recognized. One of these I reduced 
at Bellevue Hospital on the seventh day, and one on the tenth. There 
was also presented to me, at the Charity Hospital (Blackwell's Island), 
in my service, an axillary dislocation of twenty years' standing, which 
a surgeon saw immediately after the receipt of the injury and failed to 
recognize. In other cases the dislocation has been clearly made out, 
but the surgeon has been unable to reduce the bone. It has been my 
fortune to succeed in several instances where others have made a fair 
trial and have failed, but the following case leaves me no opportunity to 
boast the superiority of my own skill above that of my confreres. 

Mary Kanally, set. 49, a large, fat, laboring woman, was admitted into 
the Buffalo Hospital of the Sisters of Charity, with a dislocation of the 
right humerus into the axilla, which had occurred twelve hours before. 
This is the same woman of whom I have before spoken as having pro- 
duced the dislocation by a fall while holding upon the handle of a pump. 

Drs. Lockwood and Baker, of Buffalo, were first called, and attempted 
reduction. They made extension and counter-extension in every possible 
direction, and for ;i Long time, but to no purpose. She was then sent to 
the hospital. "Without attempting to describe minutely the various modes 
of extension and manipulation which I employed, I will briefly state that, 
having placed her completely under the influence of chloroform, the 
manipulations were made assiduously during one hour, without success. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 



695 



Fig. 275. 



On the following morning she was bled freely from the opposite arm, 
and chloroform again administered ; extension being made, in the pres- 
ence of Prof. Charles A. Lee and other gentlemen, with Jarvis's adjuster. 
After more than an hour, the effort was again suspended. On the fol- 
lowing day we made a third attempt, the patient being completely under 
the influence of chloroform, but with no better success. The chloroform 
produced a condition approaching apoplexy, and it was not again used. 
On the tenth day, assisted by Prof. James P. "White and other surgeons, 
we applied the compound pulleys, moving the arm in various directions. 
Twice we thought the reduction was accomplished, but as often as we 
proceeded to examine it attentively we 
found it was not. If it did ever pass 
into the socket, it was immediately dis- 
placed. 

The woman after this refused to sub- 
mit to any further attempts, and she 
soon left the hospital, nor have I seen or 
heard from her since. 

Sir Astley Cooper has thus described 
the appearances presented on dissection 
of a dislocation which had been long un- 
reduced : u The head of the bone altered 
in its form ; the surface toward the 
scapula being flattened. A complete 
capsular ligament surrounding the head 
of the os humeri. The glenoid cavity 
entirely filled by ligamentous matter, in 
which were suspended small portions of 
bone, which were of new formation, as 
no portion of the scapula or humerus 
was broken. A new cavity formed for the head of the os humeri on the 
inferior costa of the scapula ; but this was shallow, like that from which 
the bone had escaped." 

AN hen the dislocation into the axilla remains unreduced, the conse- 
quences are always sufficiently grave ; but they differ very much in 
degree, in character, and in persistence, according as the arm has re- 
mained a longer or shorter time unreduced, and according to the presence 
or absence of complications. These conditions will be best illustrated 
by a reference to examples. 

Wm. 8., a German, aet. 51. fell down a flight of steps while intoxi- 
cated, producing a dislocation of the left arm into the axilla. Eleven 
hour- after the accident lie was received into the Buffalo Hospital of the 
re of Charity. No attempt had been made to reduce the bone. 
The redaction was effected by myself with tolerable ease, by extending 
the arm perpendicularly above the head, while my foot pressed upon the 
top of the scapula. The head of the humerus could be plainly felt in 
the axilla, approaching the socket, until it seemed to he directly over it, 
when, on lowering the arm, it was found to he reduced. After the re- 
duction the patient could not raise the arm mere than eight inches from 




New socket, in an ancient disloca- 
tion of the shoulder downwards. 
(From Sir A. Cooper.) 



696 DISLOCATIONS OF THE SHOULDEK. 

the body. The fingers, hand, and forearm were almost paralyzed. 
Three weeks later, when he left the hospital, his arm had improved, but 
he could not flex his fingers. 

Mrs. G., set. TO, fell down a flight of steps and dislocated her arm 
into the axilla. She did not suspect the nature of the injury, and no 
surgeon was called. I was consulted one week after the accident, at 
which time she was suffering great pain from the pressure of the head 
of the bone upon the axillary nerves. We first attempted to reduce the 
bone by resting the knee in the axilla while she was sitting, but without 
success. We then placed her in bed, and with my knee in the axilla, 
the acromion process being supported by the hands of an assistant, we 
restored the bone after a few moments of pretty firm extension down- 
wards and outwards. After the reduction she could not raise her arm, 
but the pain was much abated. One month later the arm remained very 
weak. She could not raise it more than six inches toward her head, but 
I could raise it to a right angle with the body without causing pain. 
The whole hand felt numb, and was occasionally painful. The deltoid 
muscle was slightly atrophied. There was also a slight flatness under 
the acromion process behind, and on the outer side, with a corresponding 
fulness in front. 

Mary Ann Hasler, set. 47, was admitted to the hospital with a dislo- 
cation of the right humerus into the axilla. The arm had been dislo- 
cated three weeks, in consequence of a fall upon the upper and outer 
part of the shoulder. An empiric, who saw it fifteen minutes after the 
fall, and when the arm was not swollen, said it was not dislocated. On 
the fifth day a Catholic clergyman discovered that it was out, and at- 
tempted to reduce it, but was not successful. When she came under my 
notice the arm was lengthened about one-quarter or one-half of an inch, 
and hung out from the body in a condition of almost complete paralysis. 
There was very little swelling about the shoulder or arm, and the head 
of the bone could be distinctly felt in the axilla. The patient being 
rendered partially insensible by chloroform, I placed my heel in the 
axilla, and pulling moderately about thirty seconds in a direction slightly 
outwards from the line of the body, the bone was reduced. Seven days 
after the reduction she left the hospital, the arm being yet quite useless, 
though not greatly swollen. There was also a striking fulness in front 
of the head of the bone. 

Wm. Gardner, of Painted Post, N. Y., aet. 75, dislocated the right 
humerus into the axilla, twenty years before I saw him, by falling upon 
his hands with his arm extended. I found the arm weak and atrophied, 
so that he could raise it but slightly outwards from his side; he was un- 
able to move it forwards much beyond the line of his body; but he could 
carry it back quite freely. The whole hand was in a condition of partial 
insensibility. 

I have before mentioned the case of Maria Norregan, the Swiss woman, 
whose arm had been dislocated downwards seventeen years. The deltoid 
muscle has become greatly wasted; the head of the bone can be felt 
obscurely in the axilla ; the arm is shortened perceptibly; the elbow 
hangs freely "against the side; the little and ring fingers are numb, and 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 697 

also one-half of the forearm : the whole hand and arm are weak and 
atrophied : she complains also occasionally of a troublesome sensation of 
formication over the arm and hand ; she cannot straighten her fingers 
perfectly : the elbow may be raised from the side to a right angle with 
the body, but she cannot raise it herself more than one foot ; she carries 
it back a little more freely than forwards. 

In compound dislocations the prognosis must always be regarded as 
exceedingly grave. In the only example which has come under my 
notice, the circumstances attending which I shall hereafter mention in 
the general chapter devoted to Compound Dislocations, the patient died 
from sloughing of the axillary artery. Mr. Scott has, however, reported 
a case, in a boy fourteen years of age, who recovered rapidly after the 
reduction was effected, and in thirteen months his arm was nearly as 
useful as before. 1 

Treatment. — The principles of treatment in this dislocation are very 
simple and easy to be comprehended. I speak now of recent uncom- 
plicated cases of dislocation into the axilla; and, notwithstanding the 
various and sometimes almost contradictory views which surgeons have 
entertained as to the best and most rational modes of procedure, I con- 
tinue to affirm that the laws which are to govern the reduction in a great 
majority of cases are established and indisputable. 

Observe now the obvious anatomical facts, and then consider the 
inevitable inferences. 

The capsule is torn, generally extensively, along the inner and lower 
margins of the socket. The head of the bone is lodged below and slightly 
in advance of its natural position, in consequence of which the points of 
origin and insertion of the deltoid muscle and the supraspinatus are 
Beparated somewhat and their fibres rendered tense, insomuch that the 
arm is abducted and actually lengthened. 

At first, and in the most simple cases, these are the only muscles 
which are in a state of extreme tension, but after the lapse of a few 
hours, or of a few days, nearly all the other muscles about the joint, 
most of which were originally only in a condition of moderate extension, 
and some of which were rather relaxed than extended, sympathize with 
those which are Buffering the most, and a general contraction and rigidity 
ensue, increased also at the last by the supervention of inflammation and 
sequences. 

What, from these simple premises, must be the obvious practical 
deductions '.' 

That in the simplest forms of the dislocation the most rational mode 
of reduction will be to elevate the arm sufficiently to relax the over- 
Btrained deltoid and supraspinatus muscles, which, together witli the 
upper and untorn portion of the capsule, bind the head of the bone in its 
new position, and to pull gently in the same direction, in order to over- 
come the moderate resistance offered by several other muscles, bu1 whose 
u cannot be relieved by the same manoeuvre. 

Failing in this, that we shall increase the relaxation of the first-named 

- <tt, Amer. Journ. of Med. Sci., vol. \\. p. 516, Aug. 1887, from the London 
Lanoot for March \ 1887. 



698 DISLOCATIONS OF THE SHOULDER. 

muscles, by pulling at a right angle with the body, or even directly 
upwards: and meanwhile, as we carry the arm more and more upwards, 
we shall operate more powerfully against the resistance of the other 
muscles. 

If in all these modifications of the same procedure except when draw- 
ing directly upwards, we keep the arm a little back of the axis of the 
body, we shall accomplish the indications the most perfectly. 

Such are the conclusions which must be drawn from the anatomical, 
or, as Mr. Pott would call it, the "physiological," argument; and which 
assumes as its basis that the muscles with the untorn portion of the 
capsule constitute the sole or the main obstacle to the return of the bone 
to its socket. 

It must not be forgotten that in all these modes of extension, for with 
nearly all of them some slight degree of extension is found necessary, 
there must be afforded some point of resistance beyond the bone; and 
this it is really which has constituted one of the greatest impediments to 
reduction. It is not that the muscles are in such an extraordinary state 
of extension or rigidity that they must be operated against with great 
force : it is not that the margin of the glenoid fossa is an elevated bar- 
rier, like the margin of the acetabulum, over which the bone must be 
lifted before it can fall into its socket; but the explanation of the diffi- 
culty so often experienced in producing effective extension and counter- 
extension is to be sought for mainly in the fact that the scapula, upon 
which the humerus rests, is movable, being held to the body by little 
else than muscles, which, in fact, bind the scapula much less firmly to 
the body than the muscles of the shoulder now bind the scapula to the 
arm ; while at the same time the scapula itself presents very few points 
against which a counter-extending force can be properly and efficiently 
applied. 

Occasionally it will be only necessary to elevate the arm to an acute 
angle, or to a right angle with the body, when, the resistance of the 
deltoid and supraspinatus being overcome, the bone will at once resume 
its place. In several instances which have come under my notice 
nothing more has been necessary; and where it can be done, the least 
possible pain and injury are inflicted. It is the method, therefore, 
which in all recent cases I have first tried and would wish to recommend. 
By it I have more than once succeeded when other and more violent 
efforts have failed. 

At other times it will be necessary to add to this simple manipulation 
only a moderate degree of extension, such as the hands of the surgeon 
can make, without the application of direct counter-extension except 
what is effected by the weight and resistance of the body. 

Professor Moses Gunn, of the Rush Medical College, Chicago, who 
regards the upper and untorn portion of the capsule as the chief obstacle 
to the reduction, says: "For the reduction of this dislocation it is con- 
venient to have the patient sit upon the floor. The arm is then raised to 
an angle of 45 degrees from the horizontal, and intrusted to an assistant, 
while the Burgeon places his hands on the shoulder with the tips of the 
fingers in the axilla, resting on the dislocated head. The assistant now 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 699 

makes upward and outward traction, and the head glides into place fol- 
lowed by the surgeon's fingers in the axilla. The arm is then lowered 
to the pendent position, keeping up the tension till the arm is by the 
side of the body." 1 

The late Dr. John T. Darby. Professor of Surgical Anatomy in the 
University of the City of New York, informed me that he had been very 
successful in reducing dislocations of the shoulder, by adopting a rule 
similar to that which I have laid down for reducing dislocations of the 
thigh, namely, to carry the arm only in those directions in which it meets 
with the least resistance. He found that, in most cases, he could carry 
the arm up to nearly or quite a perpendicular, by humoring the action of 
the muscles : and that in this position the reduction was easily effected. I 
have no doubt that the principle, as stated by Professor Darby, is sound, 
and that in nearly all dislocations the same may be applied successfully, 
whenever we can depend upon manipulation alone. 

If. however, the bone refuse to move, we shall then be obliged to 
consider upon what point and by what means we can best apply a 
counter-extending force. Ample experience has taught me that the 
extremity of the acromion process is the only available point when we 
are making the extension in a line below a right angle, or in a line 
downwards more or less approaching the axis of the body. It has been 
supposed that the counter-extension could be made in the axilla against 
the inferior margin of the scapula ; but several obstacles are presented 
to the successful application of force at this point. The axillary space 
is narrow and deep, so that even with the ingenious contrivance of 
placing first a ball of yarn in the axilla, and upon this the heel of the 
operator, it will be found exceedingly difficult to enter the axilla without 
at the same time pressing with considerable force against its muscular 
margins : but to press upon the pectoralis major and latissimus dorsi is 
to neutralize our own efforts. If, however, the heel or the ball does 
press fairly into the axilla, it will not find the scapula readily, but it 
must impinge first upon the head of the humerus, which is always a 
little to the inner side of the scapula. If it ever is made to reach 
actually the inferior border of the scapula, and I do not think it is, the 
effect must be still only to tilt the scapula upon itself by throwing back 
its lower angle, and not to separate the glenoid cavity or its upper and 
anterior margin from the head of the humerus. 

Whatever success, therefore, may have attended this mode of practice, 
either in my own hands or in the hands of other surgeons, must be 
ascribed not to the counter-extension thus effected, but simply to the 
operation of the heel as ;i wedge, which, by insinuating itself between 
the body and the head of the hone, has thrust it outwards and upwards 
into it- socket; or to its having acted as a fulcrum upon which the 
humeru> ha- operated ;i- ;i lever. 

It is to the extremity of the acromion process, then, that we must apply 
our counter-extension when we are employing this mode of extension. 

nn. The Philosophy of Manipulation in the reduction of Hip and Shoulder 
Dislocations. Read before the American Surgical Association, 1884. Also Chicago 
Med. and Sunr Journ. and E . ! 1884. 



700 



DISLOCATIONS OF THE SHOULDER. 



The fingers or hands of a faithful assistant may answer the purpose, or, 
having removed his boot, the operator may often press successfully with 
the ball of his foot, and the more he carries the arm outwards, the more 
secure will be his seat upon the process; or we may adopt some of the 
contrivances for securing the process which have been suggested by other 
surgeons; such as a band crossing the shoulder, and made fast to a coun- 
ter-band, which passes through the armpit and against the side of the 
body. Dr. Physick, of Philadelphia, reduced a dislocation in this way 
as early as the year 1790, in the case of a patient admitted to St. George's 
Hospital, in London, while he w T as a student of medicine, and he subse- 
quently taught the same in his lectures. Physick directed that an assist- 
ant should press firmly against the process with the palm of his hand. 
Dorsey and Hays approved of the same method, 1 and perhaps a majority 
of American surgeons have regarded it favorably. 

If w 7 e pull directly outwards, at a right angle with the body, we may 
still continue to press upon the acromion process with the foot ; or we 

Fig. 276. 




N. K. Smith's method. 



may perhaps trust to the method of making counter-extension, first sug- 
gested by Nathan Smith, of New Haven, and subsequently recommended 
by his son, Prof. Nathan R. Smith, of Baltimore. Says Prof. N. R. 

1 Physick. Amer. Journ. Med. Sci., vol. xix. p. 386, Feb. 1837. Dorsey's Elements 
of Surgery, vol. i. p. 214. Philadelphia, 1813. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 701 

Smith: 1 "What surgeon of experience has not encountered the diffi- 
culty which almost always occurs in fixing the scapula?" and he then 
proceeds to give what seems to him the most effectual mode of rendering 
the scapula immovable, namely, to make the counter-extension from the 
opposite wrist. By this method the trapezii are provoked to contrac- 
tion, and the scapula of the injured side is drawn firmly toward the spine 
ami the opposite scapula. In illustration of the value of this procedure 
he relates the case of a gentleman who had suffered a dislocation of his 
left shoulder, and upon whom an unsuccessful attempt at reduction had 
already been made by a respectable surgeon. Dr. Smith, being called, 
proceeded as follows : Two gentlemen made counter-extension from the 
opposite wrist, while Dr. Smith and Dr. Knapp made extension from the 
wrist of the injured side, at first pulling it downwards, but gradually 
raising it to the horizontal direction, and then gently depressing the 
wrist. On the effort being steadily continued for two or three minutes, 
the bone was observed to slip easily into its place. 

But no position places the scapula so completely under our control as 
that in which the arm is carried almost directly upwards, and the foot is 
placed upon the top of the scapula. By this method we may succeed 
generally when every other expedient has failed ; but it probably in- 
creases the danger of lacerating the axillary artery and vein ; and even 
when employed in recent cases, it must sometimes do serious injury to 
the muscles about the joint. In Lister's case of rupture of the axillary 

Fig. 277. 




La Mothe's method, modified. 

artery, and in Agnew'e case of rupture of the axillary vein, both of which 

will again be referred to in connection with ancient dislocations, the 

dents occurred when the arm was drawn upwards. 

La Mothe was the first to recommend pulling directly upwards ; 2 but 

iv as the year 17*j4. Charles White, of Manchester, made fast a set 

1 Smith- Baltimore, 1831, p. 387 ; also Amer. Journ. 

Med. Bci., July, 1861 ; also Amer. Med. Times, Nov. 9, 18G1 ; paper by Stephen 

B _ . .M.I) 
- La Mothe, Arner. Journ. Med. Sci., vol. xix. p. 387, Nov. 1836, from Melanges 
et Chir.. Pari-. 1812. 



702 



DISLOCATIONS OF THE SHOULDER. 



of pulleys in the ceiling, and placing a hand around the wrist of the 
dislocated arm. he drew the patient up until the whole body was sus- 
pended. No pressure, however, was made upon the scapula from above, 
which is no doubt the most essential part of the process. 1 By La Mothe's 
plan, Jobert succeeded after twenty-three days, when all the usual methods 
had failed.- Sometimes this procedure is modified by placing the hand 
of the operator against the top of the scapula, as is shown in the accom- 
panying drawing (Fig. 277); and I have several times succeeded in this 
way after other measures have failed. 

A gentle movement backwards or forwards, a slight rotation of the 
limb, or suddenly dropping the arm toward the body, diverting the atten- 
tion of the patient, are little tricks of the operator, which now and then 
prove successful. 

Sir Astley Cooper thus describes his method of applying the heel to 
the axilla (Fig. i>78) : 

" The patient should be placed in the recumbent posture, upon a table 
or sofa, near to the edge of which he is to be brought ; the surgeon then 

Fig. 278. 




Sir Astley Cooper's method of applying extension with the heel in the axilla. 

binds a wetted roller around the arm immediately above the elbow, upon 
which he ties a handkerchief; then he separates the patient's elbow^ from 
his side, and. with one foot resting upon the floor, he places the heel of 
his other foot in the axilla, receiving the head of the os humeri upon it, 
while he is himself in the sitting posture by the patient's side. He then 
draws the arm by means of the handkerchief, steadily, for three or four 
minutes, w T hen, under common circumstances, the head of the bone is 
easily replaced ; but if more force be required, the handkerchief may be 
changed for a long towel, by which several persons may pull, the sur- 
geon's heel still remaining in the axilla. I generally bend the forearm 
nearly at right angles with the os humeri, because it relaxes the biceps, 
and consequently diminishes its resistance." 

1 C. White, Amer. Journ. Med. Sci.. Nov. 1836, from Med. Obs. and Inquiries, 
vol. ii. p. 273, London, 1764. 

2 Ibid., vol. xxiii. p. 237, Nov. 1838. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 703 



Fig. 279. 



He was also accustomed in some cases to reduce the dislocation by 
substituting the knee for the heel. Placing the patient upon a low chair, 
the axilla is laid over the knee of the operator, and while one hand 
steadies the acromion process and scapula, the other presses downwards 
upon the lower end of the humerus 
(Pig. 279). 

If some hours or days have elapsed 
since the occurrence of dislocation, it 
will be necessary to resort to chloro- 
form or ether for the purpose of para- 
lyzing the muscles, as well as with the 
view of preventing pain ; and it may be 
necessary, in addition, to resort to pul- 
leys, or to some similar permanent 
mode of extension. The same mea- 
sures also sometimes become necessary 
in very recent cases, especially in mus- 
cular subjects., 

In employing the pulleys we gener- 
ally operate, not exactly in a line with 
the axis of the body, nor at more than 
a right angle, but between an angle of 
45° and a right angle. 

Mr. Skey has suggested a plan by 
which we may combine the principle of 
the heel in the axilla with the pulleys, 
but which plan would, in my judgment, 
be very much improved by a counter-extending force applied to the 
acromion process. I ought to -say, however, that Mr. Skey prefers that 
the scapula should not be fixed, believing that the reduction is much 
more easily effected when the glenoid cavity is drawn downwards in the 
act of making the extension. 

"With all respect for the opinion of this distinguished surgeon, I 
cannot precisely agree with him ; and while I would be disposed to 
recommend in some cases a trial of his method of applying the pulleys, 
I would, at the same time, or certainly in the event of its failure, add 




Sir Astley Cooper's mode of operating 
with the knee in the axilla. 



Fig. 280. 




Iron knob employed by Skey, instead of the heel. 



tli<- acromial support, and especially would I advise that the arm should 

be more abducted. The following is Mr. Skey's method, as described 
by himself: 

"There is no reason why, in very muscular subjects, or in old dislo- 
cations, the same principle may not be applied conjointly with the use 



704 



DISLOCATIONS OF THE SHOULDER. 



of pulleys. For the purpose of retaining this admirable because most 
efficient principle, I employ a well-padded iron knob, which may repre- 
sent the heel, from which there extend laterally two strong straight 
branches of the same metal, each ending in a bulb or ring of about four 
inches in length, the office of which is designed to keep the margins of 
the axilla as free from pressure as possible." The iron knob is to be 
pressed well up into the axilla and attached to cords fastened to a staple ; 

Fig. 281. 




Skey's method of making extension and counter-extension with pulleys. 

the patient lying upon his back or inclined a little to the opposite side. 
The arm is then to be drawn downwards by the pulleys, " as nearly as 
possible parallel to, and in contact with, the body." 1 



Fig. 282 




Sir Astley Cooper's mode of making extension with pulleys. 

In this way Mr. Skey says that he has succeeded in reducing a great 
many dislocations, even when occurring in very muscular men, and after 

1 Skey, Operative Surgery, Amer. ed\, p. 93. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 705 

some days', weeks', or even months' duration; and he thinks the plan 
especially applicable to cases which require long and persistent exten- 
sion. 

Mr. Skey and many other surgeons prefer to make the extension from 
the hand. I have succeeded as well, and it seemed to be less painful to 
my patients, when I have followed the practice of Sir Astley, and made 
the extension from the arm. Sir Astley always made the extension 
more or less out from the line of the body, and generally almost at a 
right angle when using the pulleys ; the scapula being made fast by "a 
girt buckled on the top of the acromion," or by a split cloth (Fig. 282). 

The instrument invented by Dr. Jarvis, of Portland, Conn., called the 
adjuster, useless and even mischievous as I have found it in its appli- 
cation to the treatment of fractures, possesses considerable merit as an 
apparatus for reducing old dislocations, especially of the shoulder. The 
principal advantage which may be claimed for it is, that while the forces 
are being applied the limb may be moved pretty freely in all directions ; 
thus enabling us to employ rotation at the same time that extension is 
made. We may also lift or depress, adduct or abduct the limb without 
relaxing the extension. In the hands of American surgeons it has occa- 
sionally been successful when other means have failed. Dr. Jarvis has 
related a case presented at the Marine Hospital, at Mobile, Alabama, of 
forty-two days' standing, which he reduced on the second attempt, after 
other means had failed ; x and Dr. May, of Washington, reduced a similar 
dislocation at the end of six weeks, by the same apparatus, without, how- 
ever, having previously resorted to any other means. 2 

I have myself used the apparatus occasionally, both in my hospital 
and private practice, and can speak favorably of its operation. 

Mathieu, Robert, and Collin have modified the apparatus in several 
particulars ; illustrations of both of which modifications Poinsot has 
furnished in the French edition of this treatise. 3 

Kocher 4 flexes the forearm upon the arm ; carries the elbow against 
the side of the body ; abducts the hand, in order to rotate the head of 
the humerus outwards, until resistance is experienced ; carries the elbow 
forwards, upwards, and slightly inwards, while the arm is still flexed at 
a right angle, and the hand maintained in a position of forced abduction ; 
then the arm is rotated inwards, and the hand is carried upon the sound 
shoulder. All of these manoeuvres are to be executed as slowly and 
gently as possible. 

I must not omit to mention the practice adopted by Prof. H. H. Smith, 
of Philadelphia, according to whom nearly all dislocations of the shoulder, 
of a recent date, may be promptly and easily reduced by manipulation 
alone. His method consists, first, in flexing the forearm upon the arm, 
while, at the same moment, the elbow is lifted from the body ; second, in 
rotating the humerus upwards and outwards, employing the forearm as a 
lever; and third, in reversing this last movement, that is, rotating the 

1 Jarvis, Boston Med. and Burg. Journ., vol. xxxix. p 215. 

2 May, Ibid , vol. xxxv. p. 454. 
8 Poinsot, op. cit.. p. 825, etc. 

* Kocher, Rev. Men. de Chir., 1882, t. 2, p. 834. 
45 



706 DISLOCATIONS OF THE SHOULDER. 

humerus downwards and inwards, while at the same moment the elbow 
is carried again to the side. 1 

When the dislocation is into the axilla, this latter manoeuvre will gen- 
erally succeed; but if the head of the humerus has slipped forwards, even 
only sufficient to engage itself slightly under the tendons of the coraco- 
brachialis and biceps (approaching to, or actually in the condition of a 
subcoracoid dislocation), the outward rotation of the humerus will inevi- 
tably thrust the head further forwards, and fasten it more certainly 
underneath these tendons; while the rotation of the humerus in the 
opposite direction will alone often be sufficient to carry the head directly 
into the socket. 

Mr. John Reynders, instrument-maker of this city, has recently shown 
me a cone made of ash-splittings, braided, and which is large enough to 
embrace and fasten itself to the forearm, for the purpose of extension 
(Fig. 283). He informs me that the apparatus was imported from Ger- 
many. It is the same as that described by me many years since as the 
"Indian puzzle," and which will be seen represented in the chapter on 
" Dislocations of the Fingers." 

Ancient Dislocations of the Shoulder. — Finally, I ought to speak 
somewhat more in detail of the manner of procedure and of the princi- 
ples involved in the reduction of old dislocations, or of dislocations re- 
quiring the interposition of mechanical appliances; especially with a 
view to the more complete exposition of my own practice in these cases. 

Fig. 283. 




Indian puzzle, employed to make extension in dislocations of the shoulder. 

If the dislocation is recent, and reduction is found impossible without 
the aid of mechanical apparatus, the difficulty will be understood to con- 
sist mainly, if not altogether, in the resistance offered by the muscles. 
If, in a few exceptional cases, a "button-holing" of the head and neck 
by the capsule, or the margin of the glenoid fossa, present themselves 
as obstacles, they must be considered as unusual and extraordinary im- 
pediments, the existence of which may be regarded rather as possible 
than probable. 

Almost our sole purpose, then, it will be understood, in all recent 
cases requiring mechanical appliances, and in some ancient cases, is to 
overcome the contraction of the muscles. 

I prefer always to place the patient upon a mattress laid upon the 
floor ; two silk handkerchiefs, or two pieces of a cotton roller, are then 
laid along the radial and ulnar sides of the humerus, and over the middle 
of these, immediately above the condyles, a wetted roller is applied, its 

1 H. H. Smith, Gross's Surg., ed. of 1863, p. 152. 



DISLOCATIONS OF THE. SHOULDER DOWNWARDS. 707 

end being made last with a needle and thread rather than with a pin. 
The upper ends of the longitudinal strips, or of the handkerchiefs, are 
now turned down and tied to the opposite ends, thus converting them 
both into lateral loops. For the purpose of making counter-extension, a 
sheet is passed around the body under the axilla, and made fast to a 
staple : while an intelligent assistant is to manage the scapula with his 
naked hands, either by pulling with his fingers placed under the process, 
or by pushing with the palm of his hand and ball of his thumb. The 
pulleys, secured to a staple exactly opposite to that which holds the 
counter-extending band, are made ready, but not for the present attached 
to the arm. 

As soon as the patient is placed completely under the influence of an 
anaesthetic, the operator is ready to proceed with the reduction. It is 
my maxim never to attempt to accomplish by complicated and violent 
measures what may be done as well by more simple and gentle means. 
I think it proper, therefore, to make several attempts at reduction by 
manipulation alone, aided now by the anaesthetic, the extending and 
counter-extending bands, etc., before resorting to the pulleys. Seating 
himself upon the mattress, his boots being removed, the surgeon should 
bend the forearm to a right angle with the arm, and planting one heel 
in the axilla, with one hand he should seize upon the loops at the elbow, 
and with the other steady the hand and forearm of the patient, while he 
proceeds to make firm traction for a few seconds in the line of the body, 
or only a little out from this line. Failing in this, he may direct the 
a->i>tant to seize upon the scapula, and make counter-extension; still 
not succeeding, he may change his foot from the axilla to the acromion 
pmeess. and pull directly outwards at a right angle with the body, or he 
may swing himself gradually around until he comes to be above the head 
of the patient, and the foot presses firmly upon the top of the scapula; 
now descending again in the same direction, he will very probably find 
the limb reduced, or capable of being reduced easily, by operating upon 
it as a lever by laying it across the body while at the same moment it is 
rotated slightly inwards. 

If still the reduction is not accomplished, the pulleys must at once be 
put in requisition. The sheet, passed around the chest and fastened to 
n staple, is "nly a means of supporting the body and rendering it more 
ly : as a means of counter-extension its value is inconsiderable. To 
make fast the scapula, we must still rely mainly upon the naked hands 
of strong men, or upon a strap drawn firmly across the process and held 
in place by an assistant. 

Whenever we employ extension without the aid of anaesthetics, as 
sometimes we are compelled to do, it must be constantly borne in mind 
that it is proposed to conquer the muscles by fatiguing them, and that 
this cannot be done by a force suddenly applied, however great it may 
be. but only by gentle, steady, and long-continued extension. The 
muscles, when attacked openly and rigorously, resist, and will suffer 
laceration rather than yield, while, on the other hand, an insidious but 
persevering approach seldom fail- to end in their defeat. The same is 
true, but in a much less degree, when the patient is Insensible from 
an»sthe>ia. 



708 DISLOCATIONS OF THE SHOULDER. 

The forearm is again flexed, and the arm carried out to a right angle 
av i 1 1 1 the body, the pulleys secured to the loops, and the assistant takes 
hold upon the process, while the surgeon draws gently upon the rope 
attached to the pulleys; as soon as everything is moderately tense, he 
is to desist for a few moments. Again the rope is drawn upon gently, 
and again the progress of the extension is suspended. In this way the 
operator is to proceed during half an hour, or two hours, as the nature 
of the case may demand ; occasionally rotating the humerus, and occa- 
sionally lifting its head toward the socket. Meanwhile, it is understood 
that the principal counter-extension is made by the assistants, who must 
relieve each other, at the acromion process. The sheet in the axilla, or 
rather against the side of the chest, has some value in this respect when 
the arm is at a right angle with the body, but in itself it cannot control 
the scapula, only as it holds the body to which the scapula is attached. 
Much, therefore, as we may regret the inconvenience of making counter- 
extension by hands alone, experience and anatomy alike must teach that 
here it is the only mode. If these dislocations are reduced often by 
other methods, as no doubt they are, then it is only an evidence that in 
these examples little or no counter-extension was necessary. 

Sometimes the dislocation is not reduced when the extension is given 
up, but if then a resort is promptly made to some one of the simple 
methods already described, while the muscles are still exhausted, it very 
often happens that the reduction is easily accomplished. 

It will be prudent in all cases, in order to prevent a redislocation, 
whether the dislocation is recent or ancient, as soon as its reduction is 
effected, to place the arm in a sling and secure the elbow to the side by a 
few turns of a roller. I do not think the axillary pad necessary, and I 
am afraid it has sometimes done as much mischief as the dislocation itself. 

The following example will illustrate the variety of expedients to which 
we are obliged sometimes to resort before our efforts prove successful: 

Thomas Leeding, of Niagara Co., N. Y., aet. 52, a laborer, and a 
muscular man, dislocated his right arm into the axilla, by jumping from 
the cars when they Avere in full motion. The blow was received upon 
the shoulder. An intelligent country surgeon, assisted by several other 
persons, attempted reduction within an hour after the accident, but failed, 
and as the patient had some distance to travel, he was not brought under 
my notice until eighteen hours had elapsed. We first administered 
chloroform, and then, while an assistant held firmly upon the acromion 
process, I pulled in the line of the body, then outwards, and finally up- 
wards, but to no purpose. Having then applied Jarvis's "adjuster," 
and after the arm had been kept extended at a right angle with the body 
fifteen minutes, we removed the apparatus, and found the bone in its 
place. 

John Harrington, aet. 50, a very large and powerful man, fell while 
intoxicated, and dislocated his left humerus into the axilla. No surgeon 
was called until the tenth day, when he first consulted Dr. Dudley, who 
at once brought him to me. Without delay we applied the pulleys, and 
placing the arm at a right angle with the body, we made extension fifteen 
minutes; occasionally also rotating the arm. We then removed the 
pulleys, and while an assistant held upon the acromion process, with my 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 709 

heel in the axilla. I made extension in the line of the axis of the body, 
then outwards, and finally upwards with my foot upon the top of the 
scapula. I next seated my patient in a chair, and drew his arm and 
axilla forcibly over my knee. The bone was not yet reduced ; I there- 
fore bled him twenty-four ounces, or until partial syncope was induced, 
and proceeded to repeat most of these processes, but with no better re- 
sult. At this moment I determined to use sulphuric ether, which had 
just been introduced as an anaesthetic, and while he was completely under 
its influence the pulleys were again applied, and the extension continued 
for some time, and until the rope broke. He was then again placed in 
a chair, and the axilla brought over my knee, when in a moment the 
reduction was accomplished. 

Julia McKnight, set. 39, was admitted to ward 28, Bellevue, in Nov. 
1866. with a dislocation of the humerus into the axilla, which had ex- 
isted seven weeks and one day. The deltoid was much wasted and the 
hand somewhat numb. Before the class of medical students, the patient 
being under the influence of ether, the reduction was effected; but not 
until various methods of manipulation and extension had been tried and 
had failed. Having finally carried the arm directly upwards — La Mothe's 
method — and in this position employed extension, the arm was again 
brought down, and with moderate manipulation the reduction was effected. 
The return of the bone was sudden, and was accompanied with a slight 
grating sensation ; it was observed also, that a hard bony projection 
was left in the axilla, which was no doubt the margin of a new socket. 
The head of the humerus could be plainly seen and felt in its socket, ren- 
dering it certain that I had not broken the surgical neck of the humerus. 

John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably 
muscular, but spare, fell down a flight of stairs, and dislocated his 
left humerus into the axilla. The shoulder became much swollen, and 
was very painful, but he did not suspect a dislocation and did not 
consult a surgeon. Eight weeks after the accident he applied to me. 
Tli ere were present the usual signs of this dislocation, but the arm was 
by careful measurement one inch and a half longer than the other. 

The reduction was accomplished on the same day, in the presence of 
Dre. Lee. Webster, Coventry. Ford, and Jewett. The time occupied in 
the reduction was about two hours. An attempt was first made with the 
heel in the axilla and with violent rotation and extension. The same 
plan was repeated with the aid of ether, which was administered freely. 
Jarvis's adjuster was now applied, with no result, except that, either in 
consequence of the force employed by the adjuster, or in consequence of 
the free use of* ether, or of both, he became convulsed violently, which 
was accompanied by frothing at the mouth and other grave symptoms. 
The adjuster was removed, and the exhibition of ether discontinued. As 
soon a- the convulsions ceased, and before consciounios had returned, 
extension, rotation, etc., were again made by hands. Finally, after all 
extension was relinquished, placing my knee in the axilla, I reduced the 
bone by ;i very slight rotary action upon the arm; the bone was at once 
plainly in its socket, but the unusual length of the limb continued, being 
one inch and a half longer, though it could bo shortened to the same 
length as the other by lifting the elbow. A pad was placed in the axilla, 



710 DISLOCATIONS OF THE SHOULDER. 

and the arm secured with a sling and roller. The next day the arm 
remained in place, but it was now only one inch longer than the other. 
At the end of a fortnight it was only three-quarters of an inch longer, 
and could be reduced to the same length by lifting; the pain and swell- 
ing about the shoulder, which never were great, were subsiding, and the 
patient was dismissed. 

However skilfully our efforts may be directed, they will be found 
occasionally to fail ; either owing to adhesions which have taken place 
between the head of the bone, or rather its capsule, and the adjacent 
tendons, muscles, etc., to some extraordinary position of the head and 
neck of the bone in its relation to ligamentous or tendinous structures, 
to a filling up of the glenoid fossa, or to some other cause not fully ex- 
plained. Such failures have happened not only in the hands of ignorant 
and unskilful surgeons, destitute of appliances, but also in the hands of 
those who are the most expert, and who are the most completely pro- 
vided with all the necessary apparatus. Indeed, if the truth were known, 
it would probably be found that the number of failures after the sixth or 
eighth week has been greater than the successes. The records of sur- 
gery, however, furnish a great many examples of ancient dislocations of 
the humerus reduced after periods ranging from one month to six, or 
even longer. Sedillot 1 claims to have succeeded after one year and 
fifteen days, and Koenig 2 after eight years. 

In 1819, Weinhold, for the purpose of reducing an ancient dislocation 
of the humerus, cut the pectoralis major three fingers' breadth from its 
insertion, and obtained an easy reduction. 

Wutzer, 3 in two cases, cut the coraco-brachialis. Poinsot, to whom I 
am indebted for this statement, adds that the result is not known to him. 

Dieffenbach was able to accomplish the reduction of a forward disloca- 
tion after two years, but not until he had cut the tendons of the pectoralis 
major, latissimus dorsi, teres major, and teres minor, and had divided 
the ligaments surrounding the new joint. 4 

Simon, 5 in 1852, and Polaillon, 6 in 1881, combined subcutaneous 
incisions of the fibrous tissues surrounding the joint, with prolonged 
extension, and were thus enabled to reduce this dislocation. Poinsot, 
however, does not think these incisions were of any particular value. 

In a woman, set. 48, who had a forward and downward dislocation of 
seven months' standing, accompanied with great pain and inability to use 
the limb, H. Burckhardt 7 through an open incision divided the adhe- 
sions, and during the efforts at reduction the great tuberosity was partially 
torn off. The result was a very sensible improvement in the condition 
of the arm. 

Mears, 8 of Philadelphia, has twice practised subcutaneous osteotomy, 
in order to establish a false joint, and with results satisfactory to himself. 

1 Sedillot, Art. Lux., Die. Encyc. des Sci. Med., 2d ser. t. 3, p. 281. 
- Bloenig, by Ceppi, Rev. Men. de Chir., 1882, t. 2, p 828. 

3 Wutzer, K ronlein, die Lehre von Lux. in Deuts. Chir. von Billroth u. Lueke, 
Lieferunir, 26, p. 71. 

4 Dieffenbach, Boston Med. and Surg. Journ., vol. xxii. p. 382, from Medicin. 
Zeitung. 

nion, from Kronlein, Inc. cit. 6 Polaillon, Poinsot, op. cit., p. 834. 

7 Burckhardt, Wiirttemberg. Med. Correspond., 1878, No. 4, p. 35. 
• Blears, Phila. Med. and Surg. Reporter, Oct. 1877. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 711 

Despres 1 has had recourse, in two eases, to fracture of the neck of the 
humerus, without intending to establish a pseudo-arthrosis. Poinsot, in 
commenting upon these cases, says that the results of the two cases, as 
reported, are not likely to impress the reader favorably. 

In a case in which the head of the humerus, long dislocated, pressed 
upon the brachial plexus, causing great suffering, Dr. Edward Warren, 
of Baltimore, practised resection, in 1869, giving immediate and perma- 
nent relief. 2 

Dr. Thomas Annandale, Surgeon to the Edinburgh Infirmary, in the 
case of a woman 62 years old, with a subclavicular dislocation of six 
weeks' standing, having failed to reduce the bone, and the patient suffer- 
ing great pain on account of the pressure upon the axillary nerves, cut 
down upon the head of the humerus, along the inner border of the del- 
toid, and after separating the axillary artery, which was adherent to the 
bone, and having sawn through the surgical neck of the humerus, he 
removed the head in fragments and with great difficulty, inasmuch as it 
was firmly bound to the ribs by fibrous and bony tissues. In the course 
of this procedure he wounded the circumflex artery so near to its origin, 
that he was obliged to tie the subclavian above and below the origin of 
the circumflex. The operation w r as performed February 16, 1875. On 
the 18th the hand and forearm became gangrenous, and on the 19th she 
died. 3 

Volkmann 4 practised resection in a man, aet. 53, who had a subcoracoid 
dislocation of five weeks' standing, and which it was found impossible to 
reduce. The incisions were made through the axillary space, and at once 
opened into a cavity of the size of the fist, inclosing the head of the bone, 
and containing blood and serum. It was ascertained now that the blood, 
which still continued to flow, came from the axillary vein, which had been 
wounded by a sharp fragment of bone, separated from the lesser tuber- 
osity. The vein was ligated, and the resection made, but notwithstand- 
ing the resection the head of the humerus could be only partially replaced. 
At the end of three weeks this patient left the hospital, with some im- 
provement in the position and motion of the arm. 

In the case of a man, set. 30, with a dislocation of seven or eight 
months' standing, and in which redislocation was constantly occurring. 
Cramer 5 practised resection with most satisfactory results. 

In a case of repeated redislocations of the humerus Kuster 6 also prac- 
tion, and obtained at the end of seven weeks " very satisfactory 
results. " 

Volkmann 7 lias also practised resection in the case of a man, aet. 30, 
who had repeated, spontaneous redislocations. The incisions were made 
from the anterior surface of the arm. Subsequently the patient informed 

I) 3] : ••■-. B ill - ic de Chir. de Pari?, 1870. pp. 24 et 742. 
- Warren ire, Arner. Journ. Med. Sci., April, 1876, p. 452 ; also, Balti- 

more Med. Journ.. Sept. 1871, p. 532. 

3 Annandale. Med. Times and Gaz., May 29, 1876, p. 576. 

1 Volkmann, Popke, Inaug. diss. Halle ,1882: Anal, in Centralblatt fur Chir., 

5 Cramer. Berliner Klin. Wochenschrift, 1882, No. 2. 

6 Kuster, Kev. Mens. Chir., 1882, p. ' Volkmann, Popke, loc. cit. 



712 DISLOCATIONS OF THE SHOULDER. 

Yolkmann, by letter, that he could use his arm a great deal better than 
before the operation. 

It would be unjust to the young surgeon not to call' especial attention 
to the numerous examples of serious and even fatal accidents which have 
followed upon the attempts to reduce ancient dislocations at this joint. 

Rupture of the Axillary and other Arteries. — The late George C. 
Blackmail, of Cincinnati, a distinguished surgeon, having met with one 
of these unfortunate accidents in his own practice, had the candor to 
make a public statement of the case and of the circumstances which 
attended it. In a letter to the editor of the Western Lancet, published 
in the November number for 1856, he wrote as follows : 

••About the 10th ult., aided by yourself, I succeeded in reducing by 
manipulation, without the pulleys, a dislocation into the axilla, of eighty 
days' standing. The reduction was accomplished in a very few minutes, 
under the influence of chloroform and ether, and the next morning the 
patient left for the country, in a comfortable condition. Since that I 
have received no tidings from him. Encouraged by the result in this 
case, another patient, himself a physician, a tall, athletic man, and about 
fifty years of age, decided to submit to the same manipulation, although 
his arm had been dislocated for about sixteen weeks. The dislocation 
was downwards and inwards, and about the tenth week an unsuccessful 
attempt, by another surgeon, had been made with the pulleys, to which 
the force of six men was applied for two and a half hours. The patient 
being under the influence of chloroform and ether, aided by yourself, 
Drs. Fries, Cary, Graham, and Kauffman, I commenced by manipula- 
tions, adducting, rotating, abducting, and elevating the arm. These 
efforts had been made for about ten minutes, and the least possible 
violence employed, when a tumefaction appeared in the pectoral region, 
which, in a few minutes, attained a considerable size. Supposing that 
the axillary artery was ruptured, as no pulse could be felt at the wrist, 
a ligature was immediately applied to the vessel at the upper part of its 
course. The operation was performed about 10 o'clock A. M., and com- 
pression of the pectoral region made by means of a sponge and broad 
roller. On removing this the next morning, the tumefaction had nearly 
disappeared. The patient continued comfortable, and about nine days 
after the application of the ligature I was compelled to leave the city on 
a professional visit to Indiana. I left on Friday afternoon and returned 
on Monday morning, at which time I learned that my patient had died 
on Sunday morning, from haemorrhage at the seat of ligature." 

M. Panas 1 saw at the Hospital St. Louis, a diffuse aneurism in the 
armpit supervening fifteen days after a reduction of a dislocation (intra- 
coracoidean) which was of forty-eight hours' standing. The reduction 
had been by ordinary manual extension, while the head was pressed 
forcibly outwards by the thumbs sunk deeply into the axilla. M. Panas 
tied the subclavian artery in the neck, outside of the scaleni muscles. 
The patient succumbed three months later from articular suppuration. 

Gunther 2 reduced a recent dislocation under anaesthetics, by elevation 

1 Panas, Art. Epaule, Nouv. Die. Med. ot Chir. Prat., t. 13, p. 441. 

2 Gunther, quoted by Marchand, ThSse d'Agreg., Pans, 1875, p. 40. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 713 

and direct pressure upon the head of the humerus, in a man 20 years of 
age. who had before dislocated the same arm. At the end of three weeks 
an aneurism was discovered in the axilla. The subclavian was tied, sup- 
puration ensued, the abscess opened, and death resulted from haemor- 
rhage. 

W. Korte 1 reports a case in which a recent dislocation forwards and 
inwards was reduced by a bone-setter, an axillary tumor formed, which 
was punctured several times, and the patient died five weeks after the 
accident of septicaemia. He reports also another case of a similar but 
ancient dislocation, in which several attempts were made at reduction, 
during one of which the axillary artery was ruptured. The aneurism 
soon opened spontaneously, and the patient died of haemorrhage. 

In the case of a man, aet. 62, admitted to the General Infirmary of 
Sheffield. England, with a dislocation of eight weeks' standing, slight 
attempts at reduction, with the heel in the axilla, resulted in the forma- 
tion of an axillary tumor. The next day the axillary artery was tied, 
and new attempts at reduction were made. The patient died at the end 
of twenty-four hours. 2 

M. Letievant, 3 of Lyons, found in his wards a patient with a disloca- 
tion of twenty days' standing. The reduction was effected under chloro- 
form, but not until violent tractions had been made. It was followed 
immediately by an axillary aneurism and paralysis of the radial nerve. 
M. Letievant, after having tried successively digital and elastic compres- 
sion, resorted to ligature of the axillary artery, outside of the scalenii. 
The aneurism got well, and the paralysis eventually disappeared. 

In Carruther's 4 patient, a dislocation having been promptly reduced, 
was soon reproduced. The second reduction was again easily effected, 
but on the following day there existed tumefaction and signs of incipient 
gangrene. Carruther amputated the arm and the patient died the next 
morning. The autopsy revealed a laceration of the axillary artery below 
the origin of the subscapular. ■ 

A man 55 years of age, and having a dislocation of forty-eight days' m 
standing, was subjected to repeated attempts at reduction, which resulted 
in a diffuse aneurism. Four months later he was admitted to Charing- 
Cross Hospital. Dr. Bellamy amputated the arm at the shoulder-joint, 
and the patient died during the operation. 5 

Desanlt twice observed, after attempts to reduce old dislocations of the 
shoulder, "twmeurs aeriennes." It is quite probable, however, that in 
each case the tumor was caused by the rupture of a bloodvessel, and 
probably an artery. 6 

Pelletan, also, attempting to reduce a dislocation of four months' stand- 
ing, thought he produced a tumeur aerienne, but it being opened the 
patient bled to death. 7 Probably the axillary artery was torn. 

Malgaigne, attempting to reduce ;1 dislocation of sixty-eight days' 

1 Korte, Arch, fur Klin. Chir., P>d. 27, lift. 3, p. 631. 

2 British Med. Journ., Feb. 2, 1888. 

■ Letievant, Lyon M<'<1.. II Juil, 1878, p. 383. 
4 Carruther, Brit. Med. Journ., fcfa} 18, 1872. 

■ Bellamy, The Lancet, 1880, vol. 2. p. 260. (Poinsot, op. cit., pp. 838, 839.) 

6 Desanlt, Journ. dc Chir., t. iv. p. 301. : Pelletan, Chir. Clin., 1. ii p. 051. 



714 DISLOCATIONS OF THE SHOULDER. 

standing, was surprised by a sudden tumefaction in the axilla, and on 
the shoulder, which caused so much alarm as to induce him to discon- 
tinue his efforts. Ice was applied, and the haemorrhage, which he thought 
came from muscular branches, was arrested. 1 Verduc saw the axillary 
artery ruptured in the same manner, in consequence of which the patient 
died. 2 J. L. Petit, Dupuytren, and Nelaton met with similar cases. 
C. Bell reports an example of rupture of the artery with extensive lacera- 
tion of the muscles, and which demanded immediate amputation. Del- 
pech ruptured the artery, and his patient died immediately. 3 Flaubert 
was more fortunate, the effused blood being absorbed after a few days. 4 
John C. Warren, of Boston, tied the subclavian artery to arrest the 
progress of an enormous aneurismal tumor in the axilla, caused by the 
reduction of a recent dislocation. 5 Gibson, of Philadelphia, lost two 
patients from rupture of the artery in attempting to reduce old dislocations 
of the humerus, 6 and he relates another fatal case occurring in the prac- 
tice of David, of Rouen. Leudet, of Rouen, lost a patient in this way 
in 1825. In this latter case, and in both the cases occurring in the 
practice of Gibson, there was a fracture, also, of the lower margin of the 
glenoid cavity. Callender ruptured the artery in an attempt to reduce 
a dislocation at six weeks. 7 Mr. Lister met with the same accident. 8 

Poinsot suggests that in some of these accidents the dislocation itself, 
rather than the attempts at reduction, might have been responsible for 
the rupture of the axillary artery; and in support of this suggestion he 
cites the observation of M. Panas, 9 that the rupture always takes place 
on the level of the subscapulars. He refers also to examples furnished 
by Berard, 10 Le Dentu, 11 Adams, 12 and Korte, 13 in which the existence of 
the aneurism seemed to precede the attempt at reduction. 

Berard's patient succumbed speedily. Le Dentu's patient, in whom 
scapulohumeral disarticulation was practised, died also. Adams reduced 
the dislocation, then tied the subclavian, and the patient recovered. In 
Korte's case the dislocation, caused by a direct blow, was reduced spon- 
taneously. An aneurism ensued and the subclavian was tied, but the 
patient died of secondary haemorrhage. 

Neither of the first three cases, it seems to me, so far as their history 
is related by Poinsot, furnishes absolutely conclusive evidence that the 
rupture did not take place during the preliminary examination. In 
Korte's case one is struck with surprise that a traumatic dislocation 
should be reduced spontaneously. Yet I do not deny that rupture of 
the axillary artery may in some cases result directly from dislocation. 

1 Malgaigne, Paris ed., 1855, p. 150. 

rduc, Operat. de la Chir., 1693, t. i. p. 559. 
:: Malgaigne, op. cit. , p. 152. 

* Mgmoires snr plusieurs cas de Luxationes, etc. Repertoire d'Anat. et de Phys., 
1*27, Obs. 3. Four cases of injury to the Axillary or Brachial Vessels or Nerves. 
Warren, A.mer. Journ. Med. Sci., vol. xi., N. S., 1846. 

6 Gibson, Elements of Sur^., vol. i. p. 824, 4th ed. 

7 St Barthol. Hosp. Rep./l866. vol ii. p. 96. 
■ Med. Timea and Gaz., Feb. 1, 1873. 

9 Panas, Bull. Soc. Chir. de Paris. 1877, p. 193. 

"' Berard, Ibid., p. 193. n Le Dentu, Ibid., p. 187. 

12 Adams, The Lancet, 1880, vol. ii. p. 260. 13 Korte, loc. cit. 



DISLOCATIONS OF THE SHOULDER DOWNWARDS. 715 

Rupture of the Axillary Vein. — Froriep attempted the reduction of 
the shoulder in a woman, set. 36, the dislocation having existed twenty- 
days. The axillary vein was torn entirely across, and death ensued in 
an hour and a half. 1 

A woman came under the observation of Price 2 who had an old dislo- 
cation of the shoulder. Reduction having been effected, she died the 
next day in consequence of a rupture of the axillary vein. 

Hailey 3 reduced a dislocation easily, but two months later a tumor 
appeared in the axilla, the patient succumbed to pyaemia, and the autopsy 
disclosed a rupture of the axillary vein. 

Professor D. H. Agnew, of the University of Pennsylvania, ruptured 
the axillary vein while attempting to reduce a dislocation of six weeks. 
The woman, jet. 60, had a subcoracoid dislocation, and while the arm 
was lifted and extension made according to La Mothe's method, the vein 
was ruptured, causing a very large tumor covering the entire breast. 
Compresses and bandages were at once applied and continued for several 
weeks, the case resulting in a complete cure, but with the bone un- 
reduced. 4 

Rupture of Artery and Vein. — Platner mentions a case of rupture of 
both artery and vein, in which death ensued from subsequent rupture of 
the sac. 5 

Charles Bell reports a case in which the artery was ruptured, at the 
New Castle Infirmary, and the parts adjacent so much injured that 
immediate amputation became necessary. It seems quite probable there- 
fore that the vein was also torn, but this is not stated. 6 

Dr. H. B. Sands, of New York, in attempting to reduce a downward 
dislocation of seven or eight weeks' standing, in a lady eighty-six years 
of age, found a tumor rapidly forming in the axilla, which soon attained 
the size of a child's head at full term ; discoloration ensued, and the pulsa- 
tions of the brachial, ulnar, and radial arteries were lost. She was also 
greatly prostrated. It was evident that some vessel had given way, but 
inasmuch as she finally recovered without any surgical operation, it is 
Bcarcely probable that it was, as at first suspected, a rupture of the 
axillary artery. I ought to add that the patient was, at the time of 
attempted reduction, under the influence of ether, and that great care 
was said to have been exercised by Dr. Sands not to employ great force 
in the attempt. The reduction was not accomplished. 7 

Cerebral Accidents. — In a case reported by Lisfranc, death is as- 
cribed to cerebral congestion. 8 

Flaubert 9 in making a second attempt to reduce a dislocation of the 
shoulder, causcl what he supposed to be a cerebral haemorrhage. 

Poinsot, in commenting upon these cases, says that the frequency of 

1 Malgaigne, from Froriep. 

2 Price, quoted by Marchand, op. cit, p. 63. 

3 Hailev, Brit. Med. Joura., 1863. vol ii. p. 684. 
* Agnew, Phila. Med. Times, Aug. 16, 1873. 

Malgaigne, Pari- ed., 1855, vol. ii. p. 151. 
■ Willard, Summary of Cases, Phila. Med. Times, Aug. 16, 1873. 

Is, Med. Gaz., March 8, 1880. 
8 Malgaigne, Pari- ed., 1856, vol. ii. p. 161. 
,J Flaubert, Marchand, op. cit., p. 106. 



710 DISLOCATIONS OF THE SHOULDER. 

Byncope during the work of reduction has been remarked by M.Verneuil; 
and that M. Desprea and Gosseliu have thought that dislocations of the 
shoulder "lend themselves badly" to the use of chloroform. Poinsot 
farther suggests, that some of these cerebral accidents may be due to 
fatty emboli, or thromboses. 

Injury to Axillary Nerves, — Very many accidents of this kind have 
happened from time to time, some of which have been reported by Flau- 
bert. Malgaigne, Lenoir, Larrey, Xelaton, Panas, Marchand, Verneuil, 
and others. 1 

Legions of the Soft Parts. — Guerin tore the arm completely from the 
body, in an attempt to reduce a dislocation of three months' standing, in 
a woman 63 years of age. 2 Dr. Thomas Smith, 3 of St. Bartholomew, 
London, saw in a man. set. 58, the skin and muscles torn until the head 
of the bone was exposed, by simple manual extension with the heel in 
the axilla. The patient died on the ninth day. 

Inflammation, etc. — Mr. Hutchinson, of London, reported in 1866 
that inflammation, suppuration, and death had resulted from an attempt 
made to reduce an old dislocation of the humerus, under his own observa- 
tion. 4 .V like result followed the reduction of a recent subclavicular 
dislocation, in the practice of Dr. Courtright, of Ohio. 5 

Trelat's 8 patient died of inflammation caused by attempts at reduction 
of a Bubcoracoid, incomplete ! dislocation. The dislocation had existed 
four months and had been subjected to repeated unsuccessful attempts at 
reduction with India-rubber lacs, Jarvis's adjuster, etc.; and Norris 7 has 
seen a enormous axillary abscess caused by a successful reduction of a 
dislocation of seven weeks' standing. Norris's patient eventually got well. 

Fracture of the Humerus. — In the following case an attempt to re- 
duce an amient dislocation of the humerus occasioned a fracture of the 
surgical neck : 

Martha Hogan, ;et. TO, of Brooklyn, N. Y., was admitted into the 
Long [sland College Hospital during the spring of 1860. The dislo- 
cation had existed six weeks, and was subcoracoid. On the day of 
admission an attempt was made to reduce it, both by Dr. Johnson and 
myself, without an anaesthetic, in which we both failed. I then gave 
her ether, and now discovered that she had a fracture of the second and 
third ribs on the same side. The fractures were ununited. While 
manipulating, pulling the arm gently and rotating, the surgical neck of 
the humerus gave way. She did not survive the injury many days, and 
the autopsy confirmed this diagnosis. 

Tii December, 1 S T4. Dr. Stephen Smith, of Bellevue, met with the 
same accident in attempting to reduce a subglenoid dislocation of eight 
wc.-k-' standing, before the class of medical students. The patient, a 
man aged about 40, was under the influence of ether. Manipulation and 

L855, vol. ii. p. 161. Marchand, op. cit. ; Poinsot, op. cit. 
-' Lines, vol. ii. p. 466; Amer. Journ. Med. Sci., 1828, p. 136. 
- nith, The Lancet, 1878, vol. ii. p. 3. 
• Hut u - •: . L >nd. Hosp. Reports, vol. ii. (Cincinnati Journ. Med., Aug. 1866, 

irtright, Cincinnati Lancel and Observer, Jan. 1877. 
r - Trelat, Marchand, op cit., p. 114. 

vol. xxxvi. p. 24. 



DISLOCATIONS OF THE SHOULDEE DOWNWARDS. 717 

extension had been freely employed in various directions, but the frac- 
ture took place when, at my suggestion, extension was for a moment 
relinquished, and while Dr. Smith was rotating the humerus with the 
elbow at a right angle with the body. 

In December. 1865, Rosanna Casey, aet. 32, was admitted to Belle- 
vue with a subcoracoid dislocation of the left shoulder. The accident 
occurred six weeks before. On admission, one of the house surgeons 
attempted reduction, and, as I am informed, fractured the surgical neck 
of the humerus. After which, Dec. 9th, I attempted reduction before 
the class, the patient being under the influence of ether, but without 
success. Malgaigne has recorded four similar cases. 1 

Two cases are referred to in the Lancet, February 6, 1876; one by 
Howse 2 and the other by Sheen 3 ; in the latter of which, however, a 
suspicion is expressed that the fracture occurred at the same time as the 
dislocation. In my opinion the fracture was caused by the attempt at 
reduction. 

Summary of the Graver Accidents. — Rupture of an artery, 28 cases ; 
most of which were known to be ruptures of the axillary artery. Cal- 
lender, Lister, Blackman, and Korte tied the axillary, and the patients 
all died. The same was the fact in the Sheffield case. Warren and 
Letievant tied the subclavian artery successfully. Gibson, Gunther, and 
Panas, who resorted to the same operation, were unsuccessful. Nelaton 
tied the subclavian, but the result is not stated. 

Carruther and Bellamy practised disarticulation, and their patients 
died. Bell did the same, but the result is not stated. 

Rupture of vein alone, four cases. Price, Hailey, and Froriep's patients 
died ; Agnew's patient was saved. 

Rupture of artery and vein. This occurred in Platner's case, and 
the patient died. 

Rupture of unknown vessel, one case. No operation. Recovery. 

Lesions of the soft parts, two cases. Two deaths. 

Of the whole number, thirty-six, twenty-five terminated fatally, in four 
the results are uncertain, and seven recovered. 

Of fractures of the neck of the humerus I have reported three cases, 
and I have drawn from other sources six cases, making in all nine. 
My own patient died, but probably not in consequence of any injury 
suffered in the attempt at reduction. 

Norris has reported three cases of ancient dislocation into the axilla, 
treated at the Pennsylvania Hospital: one, of four weeks' standing, was 
reduced in thirty seconds by the aid of pulleys ; the second, which had 
existed Beven weeks, was reduced by the same means in about one hour; 
and the third, dislocated ten weeks, was left unreduced after extension 
and counter-exteiwm had beeE made for an hour. In the second case, 
however, suppuration occurred in or about the joint, and, on the tenth 
day. the abscess was opened, giving exit to a large amount of pus. He left 
the hospital with the parts about the shoulder still much hardened and stiff'. 4 

1 Ualgaigne, Paris ed., 1855, vol. ii. p. 143. 

2 How-*. 'I'h" Lsiricf-t, ]■-:«;. vol. i. p. 212, from Ghiy'a Hosp. Gaz. 1876. 

3 Sheen, Ibid., p. 211. 

* Norris, Amer. Journ. Hed. Sri., vol. xxxi. p. 24. 



718 DISLOCATIONS OF THE SHOULDER. 

Dislocation*, with Fracture of the Humerus near its Upper End. — 
I have thus tar omitted to speak of the treatment of dislocations of the 
humerus accompanied with fracture near its tipper end. The older 
writers, almost without an except ion. agree in declaring the reduction of 
these dislocations impossible, until the fracture had united. And, so late 
as the year L828, we have the report of a ease treated in this manner by 
a Burgeon in Massachusetts. Dr. Warren, of Boston, himself reduced 
the dislocation at the end of four weeks, when the fracture was found to 
have united. 1 But since the introduction of anaesthetics, immediate at- 
tempts at reduction have more often proved successful; and in no case 
can the Burgeon excuse himself for having omitted to make the effort. 

Richet reports an example of this kind in a man sixty-eight years of 
age, in whom the dislocation was complicated with a fracture of the neck 
of the humerus. The attempt was not made until the fourth day, when 
it proved successful without extension. The fracture was afterwards 
adjusted and consolidated, so that he recovered the complete use of his 
arm. 2 

At a meeting of the New York Academy of Medicine in May, 1855, 
Dr. Watson reported a case of fracture of the humerus near its head, 
complicated with a dislocation into the axilla. The patient was a robust 
man, past middle aire, and had received the injury by a blow on the 
sh«»ulder from a steam-engine. He was very much prostrated at the 
time of admission into the hospital, and the examination was not made 
until the following morning. The arm was then found lying close 
to the side, hut in other respects it presented the usual signs of a dislo- 
cation. Either was immediately administered; and while extension and 
counter-extension were applied, and a sweeping motion given to the arm, 
drawing it from the body, firm pressure with the fingers was made in the 
axilla, forcing the head toward the socket, and the bone slipped into its 
position. 3 

In the Transactions of the American Medical Association, I have re- 
ported a case of supposed dislocation, accompanied with a fracture, which 
I succeeded in reducing on the eighth day. 4 

I have,however, twice failed in attempts to reduce similar dislocations. 

The first patient, John Riley, ret. 49, was admitted to Bellevue Hos- 
pital. March :i!». 1864, having* received the injury two days before. The 
dislocation was subcoracoid, and the humerus was broken at its surgical 
neck. Having placed him under the influence of ether, assisted by Dr. 
Stephen Smith and Beveral other surgeons of the hospital, I attempted to 
reduce the dislocated bone, but after a trial, prolonged through one hour 
or more, the effort was abandoned. 

The Becond case was in a man aged about forty years, who was admitted 
to Bellevue Hospital in duly. L864, with a dislocation of the head of the 
humerus forwards, and a fracture of the Burgical neck, of four weeks' 

Med and Burg. Journ., X". 1. 1828; also, Amer. Jouni. Med. Sci., vol. ii. 

2 Richet. Amer. Journ Med. Sci., vol. xii.. new >er., p. 293, from Bulletin de 

Watson, Ani'T. Journ. Med. Sci., vol. wi., new Ber.,p. 383. 
♦ Op. cit., vol. ix. ].. !<:;. 



DISLOCATIONS OF THE HUMERUS FORWARDS. 719 

standing. A surgeon had attempted reduction immediately after the 
receipt of the injury, but had failed. We found the fracture still un- 
united, and placing him under the influence of ether, we tried faithfully, 
by pushing and pulling, and by various other manoeuvres, to reduce the 
dislocation, but without success. 

The fractures united in both cases promptly, and attempts were subse- 
quently made to reduce the dislocation, but to no purpose. 

Examples have been recorded, however, by surgeons, in which the re- 
duction has been accomplished immediately, and without much difficulty, 
by simple pressure upon the head of the bone while the patient was under 
the influence of an anaesthetic, and without the aid of extension ; indeed, 
it is quite doubtful whether extension in these cases is of any service. 
I have already said that I have once succeeded in replacing the head in 
its -ocket after the lapse of eight days. But if the surgeon were to 
fail by pressure alone, it would be proper to employ extension, especially 
with abduction, and manipulation. 1 In the event of a failure by these 
means, the case ought to be treated as a fracture, and the earliest period 
after the union of the fragments should be seized upon to accomplish the 
reduction of the dislocation. The occasional success of the older sur- 
geons by this method is sufficient to warrant the attempt. 

Compound dislocations of this joint will be discussed in a separate 
chapter deyoted to the general consideration of compound dislocations of 
all the joints connected with the long bones. 

^ 2. Dislocations of the Humerus Forwards. (Subcoracoid and Sub- 
clavicular.) 

uses. — The causes of this dislocation are the same as those which 
produce dislocation downwards into the axilla, except that it is more 
likely to occur in a fall upon the elbow or upon the hand when the line 
of the axis of the arm and forearm is thrown behind the body. Where 
my records have stated the cause, it has been ascribed to a direct blow 
upon the shoulder sixteen times, and to a fall upon the hand or elbow 
only twice. If it is the result of a direct blow, the impulse has usually 
been received rather upon the back than upon the outer side of the head 
of the humerus ; or the upper end of the bone, having been originally 
thrown directly downwards upon the inferior edge of the scapula, may 
have been made to assume the position forwards, beneath the pectoral 
muscle, in consequence of the peculiar action of the muscles, or of the 
position of the arm in an attempt to rise. By this latter mode of expla- 
nation, the dislocation forwards is consecutive only upon a dislocation 
downward-. 

In several instances which have come under my notice the dislocation 
has been due to muscular action alone. In one example the dislocation 
occurred frequently in consequence of epileptic convulsions. This was 
in the person of ;i lad. aet. 1*. of a slender frame and feeble muscles. 
"When the dislocation had taken place, he was frequently able to reduce 
it himself: sometimes he was obliged to call upon a surgeon, and at 

1 Hartshorne, Ca.<-e reduced by Manipulation. Amer. Journ. Med. ><•!., -Ian. 1866, 

pp. 273-4. from Med. Examiner. 



720 l'ISLOCATIONS OF THE SHOULDER. 

other times he left it out a day or two, or until it became reduced spon- 
taneously. This spontaneous reduction generally took place at night, 
during sleep. At the time he called upon me the bone had been out 
two days, and he could not reduce it. I administered chloroform, and 
then made repeated and prolonged efforts at reduction, adopting all the 
usual modes of manipulation, but without resorting to mechanical appli- 
ances. The father now refused to allow me to proceed, and he was 
taken home with the bone unreduced. The following day he called at 
my office, to say that during the night, while asleep, and, he thinks, 
while turning over in bed, the bone suddenly resumed its place. 

Drs. Edward L. Pardee and Glover C. Arnold, of this city, have re- 
cently met with a case of simultaneous dislocation of both shoulders, in 
a man set. 38, caused by a fall from a carriage, his arms being extended 
in front of him, and the force of the concussion being received upon his 
hands. Both of the dislocations were subcoracoid ; and they were easily 
reduced by Dr. Arnold. 

Surgical writers occasionally refer to similar examples, but the num- 
ber of cases of double dislocation on record is small. Most of those 
recorded have happened when the arms were extended in front of the 
l»<»dv. as in Dr. Pardee's case just cited; and the dislocations were 
generally subcoracoid. 

Pathology. — Omitting for the present to speak of partial dislocations, 
the existence of which, as a form of traumatic dislocation, I am pre- 
pared to question, I shall proceed at once to describe the anatomical 
relations and the various lesions which generally accompany a complete 
dislocation forwards. 

Of these we shall observe two principal varieties, differing mainly in 
the degree or extent of the displacement. 

Thus we may find the head of the humerus resting beneath the eora- 
coid j)rocess (subcoracoid), having the conjoined tendon of the short head 
of the biceps and of the coraco-brachialis lying upon its anterior surface, 
while its posterior and outer surface rests upon the venter of the scapula 
in front of the glenoid fossa ; in which position it has usually thrust up, 
to a greater or Less extent, the belly of the subscapular muscle. 

Sir Astley Cooper, Fergusson, and others, when mentioning this form 
of dislocation, call it a "dislocation into the axilla;" by Boyer it is called 
a •• primary luxation forwards." Dr. Wood, of New York, has reported 
an example, accompanied with a fracture of the neck of the humerus, 
which he has named " dislocation under the subscapulars muscle." The 
drawing which accompanied the report, made from the autopsy, suffi- 
ciently -hows that it was a dislocation of the same character as that 
which 1 Mm now describing. 1 Dr. Parker has called attention to a 
similar case, an account of which was first given in Reese's edition of 
< looper'a Surgical Dictionary. The head of the humerus reposed in the 
"subscapular fossa." 8 By Mal^aigne, Vidal (de Cassis), and others, 
this i- called a subcoracoid dislocation, a term which, as being more dis- 
tinctive and appropriate than either of the others, I shall choose to adopt. 

1 Wood, New York Journ. of Med., May, 1850, p. 282. 
* Parker, Ibid., March, 1852, p. 187. 



DISLOCATIONS OF THE HUMERUS FORWARDS. 



721 



In the second variety, the head, having escaped from underneath the 
coracoid process, is made to approach nearer to the sternum, so as to 
apply itself more or less closely to the inferior edge of the clavicle (sub- 
clavicular). In which case the head and neck will be placed behind the 




Fig. 285. 




Subcoracoid dislocation. 



Subclavicular dislocation. 



pectoralis minor, and also behind the short head of the biceps and 
coraco-brachialis ; or between these several muscles on the one hand, 
and the serratus magnus, covering the second and third ribs, on the 
other hand. 

Upon the appearances which accompany this more advanced form of 
dislocation writers have generally based their descriptions, diagnosis, 
treatment, etc., of forward dislocations. 

In either form of the accident, the deltoid, with the supra- and infra- 
spinatus, is greatly stretched, and the two latter sometimes torn ; the 
subscapulars is displaced upwards and backwards, while its tendon is in 
some instances completely wrenched from the head of the humerus. Mr. 
Erichsen has seen the lesser tubercle itself completely broken off in two 
examples of this accident which he has been permitted to examine after 
death. 1 Occasionally the axillary nerves are carried forwards with the 
head of the bone ; and in this case the pain produced by their being thus 
pressed upon is even greater than in dislocations into the axilla. 

In this accident, as in dislocation downwards, the long head of the 
biceps is sometimes broken ; the circumflex nerve may be contused or 
ruptured, and the capsule is generally torn very extensively. 

Symptom*. — If the dislocation is subclavicular (Fig. 285), a depres- 
sion exists under tlie outer end of the acromion process, extending also 
underneath its posterior margin ; the elbow hangs away from the body, 
and a little backwards ; the axis of the limb is much changed, being 
thrown inwards in the direction of the middle of the clavicle, the whole 
body inclining moderately to the same side; there is also more or less 



1 Erich^en. .Science and Art of Surgery, 2d Arner. ed., p. 
46 



200. 



722 



DISLOCATIONS OF THE SHOULDER. 



inability to move the arm. especially in a direction forwards or outwards; 
a fulness is seen underneath the clavicle, and to the sternal side of the 
coracoid process, occasioned by the head of the humerus, the head mov- 
ing with the Bhaft; the arm 'is lengthened. To these we may add the 
common sign of all dislocations of the humerus, mentioned by Dugas, 
viz.. the impossibility of placing the hand upon the opposite shoulder 

Fig. 286. 




Showing untorn posterior half of capsule in subcoracoid dislocation of humerus. (Gunn.) 



while ;it the same moment the elbow is made to touch the front of the 
chest. 

If the dislocation is forwards, but subcoracoid, the head of the bone 
will he found below this process and deep in the anterior margin of the 
axillary fossa. It cannot, therefore, be so distinctly felt; but the other 
signs are the same ;i< in the dislocation forwards under the clavicle, ex- 
cept thai the arm i- usually longer than the opposite arm. 

Prognosis. — While on the one hand experience has shown that the 
axillary aerves and artery arc Less liable to suffer serious and permanent 
injury than in dislocation downwards (subglenoid), and that the capsule, 
with tic tendinous and muscular tissues about the joint, are no more 
liable to laceration — on the other hand, the difficulty of reduction has 
been often increased, and consequently a large number of examples, in 
proportion to the actual Dumber which occur, have been left unreduced. 

Dr. Norris relates ;i case which the surgeon who was first called sup- 

ppsed to be ;i mere contusion, hut which, on being admitted to the Penn- 

mia Hospital, three months after the accident, was found to be a 

dislocation forwards under the clavicle. The arm was almost useless. 



DISLOCATIONS OF THE HUMERUS FORWARDS. 72o 

Dr. Norris made extension and counter-extension with compound pulleys 
nearly an hour, but to no purpose : and finally, at the request of the 
patient, the attempt was given over. 1 

Treatment. — The same rules of treatment which I have established in 
relation to dislocations into the axilla (subglenoid) will be found to be ap- 
plicable to this dislocation ; with the exception that the position of the arm 
in manipulation, or in extension, will be at first somewhat in a line back- 
wards, and that our efforts will frequently have to be continued with more 
perseverance, although with less fear of injury in consequence of supposed 
adhesions between the artery and the adjacent tissues. The extension also 
must alwavs be made downwards and outwards, if the dislocation is sub- 
clavicular, until the head of the bone has escaped from beneath the 
coracoid process ; we may then pull directly outwards or even upwards, 
while at the same moment pressure is made with the hand upon the head 
of the bone in the direction of the socket, and the arm is rotated inwards. 

Fig. 287. 




Subcoracoid dislocation. 

If the dislocation is subcoracoid, our modes of procedure need scarcely 
vary in any respect from those which I have recommended for disloca- 
into the axilla. 

Professor Grunn, of Chicago, having in mind the probable resistance 
offered by the posterior and untorn portion of* the capsule, directs that, 
in the snbcoracoid dislocation an assistant shall fix the shoulder while 
the surgeon raises the arm to a horizontal position, carries it backwards, 
rotates it externally, and draws it into position. 2 



1 Norris, Amer. Journ. Med. Sci., vol. xxv. p. 279. 

2 Gunn. loc. cit. 



7-4 DISLOCATIONS OF THE SHOULDER. 

Professor Guns does Dot fail to observe, however, that this method 
does not always succeed, owing, as he thinks, and as others have suggested 
before, to the fact that the head lias slipped through a narrow rent in the 
capsule. The same thing happens occasionally, he believes, in other 
dislocations of the Bhoulder. To shoulder dislocations complicated by 
this peculiar pathological condition, he applies the term " anomalous." 
•• The escaped head," says Professor Gunn, " under such circumstances, 
would be tinn.lv grasped by the edges of this fissured opening in the 
capsule, in Buch a manner as to foil all mere manipulatory efforts. I 
have three times encountered what I have considered to be this state of 
the parts. In one case it was my fortune to be able to demonstrate the 
correctness of these views. It was an old forward dislocation, when, 
after breaking up the adhesions, I was unable to cause the head to reenter 
the Bocket. The uselessness of the arm and the necessity of relief, owing 
to the dependence of a family on this arm, induced me to cut down upon 
the dislocated head, when I found the condition above described. I 
freely divided, with a bistoury, one border of this slit in the capsule, and 
replaced the head in the glenoid fossa. This experience was before the 
era of antiseptic precaution, and although a prolonged suppurative history 
followed, a final satisfactory recovery was realized. 

u The other two cases were recent axillary luxations in which no 
manipulatory effort was sufficient to alter the relation of the displaced 
head to the socket. Free rotation, backwards and forwards, through 
nearly all the three hundred and sixty degrees, failed to enlarge the 
opening sufficiently to permit reduction. Resort was then had to the 
compound pulley, and extension carried to the ultimate verge of temerity 
produced signs of laceration of ligamentous structures, but no snap of 
reduction. Extension was discontinued, and then simple manipulation 
reduced the luxation at once." 

Professor Gunn must permit me to say, that while I do not doubt that 
"buttonholing" the head is sometimes a cause of the irreducibility of 
recent shoulder dislocations by the ordinary methods of manipulation, 
yet it is not plain to me that, in the case of the ancient dislocation cited 
by him. the hands, which being cut permitted the bone to return to its 
<o«-kct. wore not supplementary or adventitious structures. Nor am I 
prepared t<» admit that in all recent cases, where well-directed manipula- 
tion 'loos not effect reduction, the impediment consists solely, or in all 
cases, m a buttonholing of the head. Nor do I understand that this 
distinguished Burgeon intends to say so, although his language might 
perhaps admit of this construction. 

The plan adopted in the following case has been found sufficient in 
ral examples of subcoracoid dislocation: 

Mr. McA., of Buffalo, set. 73, moderately muscular, fell through a 
trap-door. Btriking upon his right elbow, and dislocating the humerus 
forwards. Within two hours after the accident, I found the head of the 
bone resting under the coracoid process, where it could be distinctly felt 
and Been. There was a marked depression under the acromion process, 
and the arm was carried out from the body and slightly back. He had 
not Buffered much pain. The patient was seated in a chair, and while 
Dr. Lemon, who was at that time my pupil, supported the acromion pro- 



DISLOCATIONS OF THE HUMERUS FORWARDS. I'll 

cess. I pushed the head of the humerus outwards toward the socket with 
niy left hand, while with my right I pulled gently upon the arm in the 
direction of the axis of the body. After about twenty seconds it slid 
suddenly into its place with an audible snap. 

Simple manipulation alone will also be found sufficient in many cases 
of subclavicular dislocation. 

A German. Simeon Grennas. ret. 21, fell upon an icy sidewalk, and 
dislocated his right humerus under the clavicle. We found him about 
an hour after the accident, sitting with his head inclined to his right side, 
and supporting his elbow with his left hand. A marked depression ex- 
isted under the outer end of the acromion process, and instead of the 
usual fulness there was a flatness under the process behind. The elbow 
was carried out from the body, and very slightly backwards. While Dr. 
Boardman supported the acromion process I lifted the elbow from the 
side, carrying it first upwards and backwards, and then forwards, making 
thus a short detour with the arm, and when the manoeuvre was nearly 
completed the bone slid into its socket with a slight snap. No extension 
was used, and no more force employed than was sufficient to lift and 
rotate the arm. He was not at the time of the reduction faint, nor were 
his muscles relaxed from any other cause. 

More than once I have accomplished the reduction by extension made 
directly upwards, as in the following example : 

A gentleman, forty-five years of age, had his left shoulder dislocated 
forwards under the clavicle in a railroad collision, on the 8th of October. 
1858. A young surgeon had been making extension in various ways for 
half an hour, when, by placing my foot upon the top of the scapula and 
drawing the arm directly upwards. I accomplished the reduction imme- 
diately and without much effort. Six months after the accident, I found 
the deltoid muscle considerably wasted, and he was still unable to raise 
his arm to a right angle with the body. 

I have in this way also reduced a dislocation which had existed seven- 
teen days, the nature of the accident having been misunderstood by the 
attending surgeon. The man was twenty-three years old, and quite 
muscular. The dislocation had been produced by a severe blow received 
directly upon the shoulder, and the arm was still considerably swollen 
and very tender. The reduction was accomplished in a few seconds while 
the patient was under the influence of chloroform, by my hands alone, 
aided only by the pressure of the foot upon the top of the scapula. The 
method adopted successfully in both of the preceding cases, namely, 
pulling directly upwards, ought generally to be considered a last resort, 
inasmuch as it especially exposes the axillary artery, vein, and nerves to 
injury. 

In December, 1857, Dr. White, of Buffalo, and myself, reduced ;i sub- 
clavicular dislocation of tin- right shoulder, which had existed sixty day-. 
in a man Bixty-eight year- of age. The surgeon who first saw the man 
thought it was only a sprain or a severe bruise. When li<- came to 
Buffalo, the whole limb was enormously swollen, and neither Dr. White 
nor myself bad much expectation of* accomplishing a reduction without 
sort to pulley- and anaesthetics. 1I<- was, however, placed upon the 
floor, and after extension made for about half an hour, during which time 



726 DISLOCATIONS OF THE SHOULDER. 

we had palled the arm in various directions, upwards, outwards, and 
downwards, I a1 last succeeded while my heel was placed in the axilla, 
and while the limb was undergoing a Blight rotation. No anaesthetic 
was employed. 

Dr. M. C. Cuykendall, of Bucyrus, Ohio, informs me that he has 
recently reduced a subclavicular dislocation on the sixty-fourth day, in a 
man 62 years old, by the following method: "As a last resort I secured 
the pulleys to the arm above the elbow, making the counter -extension 
with Skey's knob in the axilla, flexed the arm and made extension down- 
wards and forwards: and when well extended I moved his body under 
the pulley ropes, so as to bring the arm forcibly across the breast ; then, 
keeping up the extension, I had Dr. Richey place his knee upon the top 
of the scapula, and lock his fingers around the elbow, while I placed my 
knee against the elbow and locked my fingers around the top of the 
scapula, and directing the extension removed, we forced the bone upwards 
and outwards to its sockets;" adhesions were felt to give way, and the 
restoration of the bone was found to be complete. 

It will be understood that this method did not succeed until after 
repeated and long-continued efforts had been made by other methods, 
-uch as pulling down, pulling out, and pulling directly up. Dr. Cuy- 
kendall informs me that this is the second time he has succeeded in 
"completing" the reduction of old dislocations of ' the shoulder by this 
manoeuvre. 

These several cases are mentioned that the surgeon may understand 
how impossible it is always to establish absolute and invariable rules of 
procedure which shall be applicable to every accident of this character. 
The method which will succeed readily in one case may fail completely 
in another, although belonging to the same class, and not apparently 
differing in its anatomical relations. Before relinquishing the attempt, 
we ought to have put into requisition all the expedients which the ex- 
perience of other surgeons has show r n to be worthy of a trial. 

During the year 1865, two ancient subcoracoid dislocations came under 
my observation at Bellevue Hospital. One of these cases, in the person 
of James Thompson, set. 49, had existed tw T o years or more. He was 
employed about the hospital as a carpenter, and had a tolerably useful 
arm. The second, in the person of Rosanna Casey, ?et. 32, had existed 
sis weeks when she was admitted. Various attempts had been made to 
reduce the dislocation before admission. During the week following her 
admission, an attempt was made at reduction by Dr. Verona, an intelli- 
gent house Burgeon, subsequently by Dr. James R. Wood, and at the end 
of three months the attempt was made by myself, before the class of 
medical students, the patienl being each time under the influence of an 
anaesthetic. She was finally discharged with the bone still unreduced. 

Mary Coffee, set. 46, was admitted also to the Charity Hospital, in 
Fob. L864, with the same dislocation, which had existed six months, 
haying been mistaken al firsl for a fracture. I found her arm free from 
swelling or paralysis, and moving quite freely in its new 7 socket, and de- 
cline.) to make any attempt at reduction. 

July _ v . 1873, an [rishman, about 40 years of age, was admitted to 
is's Bospital with a subcoracoid dislocation of the humerus of 



DISLOCATIONS OF THE HUMERUS FORWARDS. 727 

eight or nine -weeks' standing. The surgeon who first saw him believed 
that he reduced the dislocation, but several weeks later he found it was 
again out of place, and he tried ineffectually to reduce it. My own 
eftorts. continued for an hour or" more, were equally unsuccessful. 

The two following cases are recorded in order that they may illustrate 
the apparent inutility of a successful reduction in some cases. 

William E. Disbrow, of Bridgeport, Conn., received a subcoracoid dis- 
location of the right arm, in consequence of a violent and direct blow, 
May 9. 1870. Dr. George Lewis, of Bridgeport, a very intelligent sur- 
geon, reduced the dislocation within half an hour, the patient being 
under the influence of ether. The restoration of the bone was complete, 
and attended with an audible sound. The arm was subsequently very 
painful, and at the end of three weeks Mr. Disbrow consulted a "natural 
bone-setter,"' who manipulated the limb violently, and perhaps dislocated 
it. July 9, 1870, eight weeks after the original accident, I found the 
bone unreduced, and in the presence of a number of medical gentlemen 
at Charity Hospital, effected reduction. The patient was anaesthetized, 
and the reduction was accomplished only after considerable extension 
and manipulation had been practised ; the return of the bone to its socket 
being accompanied with a grating sensation. A thick pad was then placed 
in the axilla, and the arm and forearm secured across the front of the 
chest. Mr. Disbrow remained under observation for some time ; but it 
was soon evident that the head of the bone was gradually receding from 
the socket, and that he was not to have a very useful limb. 

Jan. 10, 1875, Leonard Ball, i"et. 40, was thrown from a carriage at 
Norwich, Conn., causing a subcoracoid dislocation of the left arm. Five 
days later Dr. Patrick Cassidy, of Norwich, reduced the dislocation, the 
reduction being accompanied with a grating sensation. Four days later 
Dr. Cassidy found the arm again dislocated, and he again reduced it. 
Feb. 11 tli. thirty-two days after the original accident, the arm was ex- 
amined by myself and other visiting surgeons at Bellevue. Some of the 
gentlemen doubted whether it might not be a fracture of the surgical 
neck of the scapula. In my opinion it was a dislocation. On the same 
day before the class, and under ether, I effected reduction by manipu- 
lation, very little extension being employed. The arm was, however, 
manipulated in various directions, and considerable adhesions were torn 
before success was attained, the bone returning to its socket suddenly, 
and with a grating sensation, while the heel was in the axilla, and I was 
pulling moderately upon the arm. No one doubted the fact of reduc- 
tion: the arm was now done up as in the preceding case, and the patient 
remanded to his ward. 

A few days later I found the head of the bone had receded from its 
socket, and was evidently tending to assume the position in which I first 
saw it : and tin- motions of the joint were very limited. He was dis- 
charged from the hospital after two or three weeks, and I have not seen 
him since. 

It is quite probable thai among the successful cases of reduction of old 
dislocations of the shoulder, reported from time to time, many have com- 
pleted their history in a similar manner. Possibly there may have been 
in each of these examples a fracture of the inner lip of the glenoid cavity, 



728 DISLOCATIONS OF THE SHOULDER. 

a condition which li;is been verified in several autopsies of old shoulder 
dislocation. 

The rapid changes which often take place in the socket, and in the 
condition of the adjacent tissues, may also account for the difficulty which 
we often experience in reducing these dislocations, and of retaining them 
in place after reduction. In Professor Lister's case, already referred to, 
at the end of Beven weeks there was a complete socket formed, smooth, 
cartilaginous, and partly hony; and strong fibrous bands had formed 
between the coracoid process, the surgical neck of the humerus, and the 
axillary artery, containing a spiculum of bone. 

In the case of a woman whose shoulder had been dislocated six 
weeks, sent to me Nov. 3, 1880, by Dr. Payne, of this city, I was 
unable to effect reduction. During the examination a well-marked exos- 
tosis was felt upon the ribs near where the head of the humerus was 
resting ; and I have already related the case reported by Mr. Annandale, 
in which, in a dislocation of six weeks, while practising resection, he 
found the head of the humerus united to the ribs by fibrous and bony 
tissues. 



^ 3. Dislocations of the Humerus Backwards. (Subspinous.) 

This form of dislocation has been seldom met with. Only two cases, 
according to Sir Astley Cooper, occurred in Guy's Hospital in thirty- 
eight years ; but in the last edition of Sir Astley Cooper's treatise on 
F/ttrtures and Dislocations, edited by Bransby Cooper, nine cases are 
mentioned. 1 Sedillot, 2 Malgaigne, Desclaux, 3 Van Buren, 4 W. Parker, 5 
Lepelletier, 6 Trowbridge, 7 Physick, Snyder, 8 Stephen Smith, and myself, 
have each seen one example. Examples have also been seen by Dupuy- 
tren, Arnolt, Best, Levacher, Berard, Fizeau, Velpeau, Fergusson, Kirk- 
bride, 9 and by Rogers. 10 

To these the researches of Poinsot 11 have added the observations of 
Lacaussade, Ph. Boyer, Goyrand, Alaboissette, Enright, Laugier, 
Bouisson, IN el. Markham, D. Molliere, Ball, C. Perier, Despres, Duplay, 
Sebilleau, Schmidt, and Tillaux. 

Dr. Stephen Smith's case was seen by myself ten days after the acci- 
dent, by courtesy of Dr. Smith. The patient, John Creswell, set. 36, 
fell down a flight of stairs Sept. 11, 1881, striking on the front of his 
shoulder. A surgeon, who saw him a few hours after, thought it was 
simply a bruise. Sept. 21, he was an inmate of Bellevue Hospital. 
The head of the humerus could be distinctly seen in its new position, and 
there was a marked depression under the acromion process, especially in 

I looper, <>)>. fit., p. 352. 
- Sedillot, Ain.T. Journ. <>\' Med. 8ci., vol. xiii. p. 551, Feb. 1834. 
Desclaux, New York Journ. of Med., Nov. 1851, p. 109, from Revue Medicale. 
d Buren, [bid., Nov. 1851, p. 110. 
•'• Parker, [bid., March, L862, p. 186. 
'• Lepelletier, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Arch. Gen., Nov. 1834. 

I I • . Boston Med. and Surg. Journ., vol. xxvii. p. 99. 

• Gibson's Surgery. ■ New York Journ. Med., March, 1852. 

Med. Times, November 9, 1861, vol. v. p. 303. 
•' Poinsot, French ed. of thia treatise, p. 800. 



DISLOCATIONS OF THE HUMERUS BACKWARDS. 729 

front. The elbow hung very slightly from the body, and scarcely more 
forwards than the opposite elbow. He could carry it forwards pretty 
freely, and a little out, but he could not carry it back. He suffered very 
little pain, and there was no swelling of the arm or hand. On the fol- 
lowing day Dr. Smith reduced the dislocation easily, by pulling the arm 
forwards, and at the same time pushing upon the head from behind. Dr. 
Smith informs me, however, that the bone became displaced on the fol- 
lowing day : but that it was easily reduced, and afterwards remained in 
place. 

Causes. — One of the patients mentioned in Mr. Cooper's book had his 
shoulder dislocated backwards in an epileptic convulsion ; one had fallen 
upon his shoulder : another met with the accident while pushing a person 
violently with the arm elevated ; and a fourth, seen by Coley, was "pulled 
down by a calf which he was driving, a cord having been tied to one of 
the calf's legs, and being held fast by the man's hand." Markham's 
patient being thrown from his horse and holding upon the bridle with 
his right hand, the arm was drawn forcibly upwards. Despres's patient 
had his left arm engaged in the collar of his horse, when the animal 
lifting his head suddenly threw his arm upwards. Bell's patient, a 
miner, set. 18, had been caught in an earth-slide when his arm was 
extended upwards. My own patient, Frederick Kretner, had his arm 
caught in machinery on the 14th of January, 1860. The dislocation 
was discovered when I was preparing to amputate the arm soon after 
the accident occurred. Pile's patient, a woman, had her arm forcibly 
twisted by her husband during an altercation. Desclaux's patient fell 
from a height with his arm in front of him. The same was the fact with 
Molliere's patient, except that the fall was upon the sidewalk. In the 
case seen by Dr. Parker, of Xew York, a woman, aet. 60, had fallen for- 
wards and struck upon the outside of her elbow, arm, and shoulder. No 
attempt was made to reduce it until the fourteenth day, she not having 
for some time called the attention of any surgeon to its condition. Trow- 
bridge's patient was thrown from a horse, striking on the palm of his 
hand. With the patient of Perier the dislocation was recurrent, but it 
occurred in the first instance during an epileptic fit. 

Pathology. — Mr. Cooper has given us a careful account of the dis- 
section in the case of Mr. Complin, already alluded to, whose arm had 
been dislocated by muscular spasm. This gentleman was fifty-two years 
of age, and had been subject to epileptic fits, in one of which the shoulder 
was dislocated. Many attempts were made to reduce it, but although it 
seemed to be easily drawn into its socket by extension merely, yet, as 
-on as the force ceased, the head of the bone slipped again upon the 
dorsum scapulae, and in this situation it was finally permitted to remain 
until his death, which did not take place until five years after. In the 
meantime lie was able to move the limb but very slightly, so that bis arm 
was almost aseless. 

Mr. Cooper, to whom the arm was sent after death, found the head <»f 
the bone resting under the spine of the scapula, and against the posterior 
edge of the glenoid fossa, where it bad formed a slight depression, and 
the head itself had become somewhat changed in form by absorption. 
The tendon of the subscapularis muscle and the internal portion of the 



730 



DISLOCATIONS OF THE SHOULDER. 




capsular ligament were torn at the point where the muscle was inserted, 
but the greater portion of the capsule remained, having been pressed back 
by the head of the bone. The suprasinatus was stretched, while the 
infraspinatus and teres minor were relaxed. The long head of the biceps 
was elongated, but not ruptured. The glenoid fossa was rough and 
irregular upon its surface, the cartilage being absorbed. 

The fact that the bone would not remain in place when reduced, was 
explained by the rupture of the subscapulars, and the consequent loss 

of antagonism to the action of the in- 
Fig. 288. fraspinatus and teres minor. 1 

The accompanying drawing is a 
copy of that furnished by Mr. Cooper, 
to illustrate the position occupied by 
the bone. 

I ought to mention that this case 
has been regarded by Vidal(de Cassis), 
Malgaigne, and others, as only suba- 
cromial, and as a variety of the dis- 
location backwards, differing from that 
in which the head of the bone occu- 
pies a position underneath the spine. 
But as I can see no difference except 
in the degree or extent of the dis- 
placement, I prefer not to regard the 
Subspinous dislocation. distinction made by these surgeons. 

Laugier, who dissected a recent 
case, found the tendon of the subscapularis torn from its attachment. 
The same was the fact with the supraspinatus, and the head, having 
passed between the infraspinatus and the teres minor, lay exposed under 
the deltoid. 

In Malgaigne 's case the infrascapularis was intact ; but the greater 
tuberosity was torn off, and remained attached to the infra- and supra- 
spinatus muscles. The head, having passed between the teres minor and 
the infraspinatus, was situated under the deltoid, below the posterior 
angle of the acromion, one-third of the articular surface overhanging the 
glenoid cavity. 

Perier dissected the arm of an epileptic woman who had been subject 
to recurrent backward dislocation. The capsule was not ruptured; the 
• •liter margin of the glenoid cavity was partially absorbed; the head lay 
slightly overhanging the glenoid cavity under the acromion process, and 
was greatly changed in form and texture. 

Kronlein describes a specimen contained in the Museum of the Clinic 
at Berlin, in which the head had rested just back of the glenoid cavity, 
where if had formed for itself a complete bony socket. 

Symptoms. — The signs of this accident are, a projection under the 
-pine of the scapula, produced by the head of the bone, the head being 
obedient to the motions oi the arm; a corresponding depression in front 
and under the outer extremity of the acromion process; a wide space 



Sir Astley Cooper, op. cit., p. -°>54 



DISLOCATIONS OF THE HUMERUS BACKWARDS. 731 

between the head of the bone and the coracoid process, into which the 
fingers may be pushed deeply; the axis of the shaft of the humerus 
directed upwards and outwards toward a point posterior to the glenoid 
fossa. The forearm is usually carried forwards across the chest, and the 
humerus rotated inwards, unless the subscapularis muscle is torn. Im- 
mobility exists, but the motions of the arm are not generally so much 
impaired as in either of the other dislocations; and finally, as in all 
other dislocations of the humerus, the hand cannot be laid upon the 
opposite shoulder while the elbow touches the front or side of the chest. 
In Parker's case the elbow was thrown outwards, although the arm was 
carried very much across the chest. In Smith's case the arm was nearly 
vertical. Desclaux's patient held his hand upon his head, with his arm 
horizontally across his body. 

In Ball's case the position of the arm was also horizontal. In Duplay's 
patient the arm was hanging beside the body with a slight rotation in- 
wards, the elbow being carried a little forwards. In Markham's patient 
the arm hung beside the body and was immobile. 

Usually the diagnosis will be easily made ; in my own and Smith's 
case the position of the head of the bone was easily recognized, but Sir 
Astley relates one case in which, on the morning following the accident, 
a surgeon was unable to discover the dislocation, and on the seventeenth 
day Bransby Cooper failed to make the diagnosis; nor, indeed, on the 
twenty-third day did Sir Astley himself determine that it was a disloca- 
tion, until he had unexpectedly reduced it while manipulating upon the 
arm. In a second example, Sir Astley at first believed it to be a frac- 
ture, but a more careful examination showed it to be a dislocation back- 
wards. In this instance the limb could not be rotated outwards, as the 
subscapularis was not torn, and continued to offer resistance when the 
arm was moved in this direction ; he was also suffering much more pain 
than did the other patients, owing, as Sir Astley thinks, to pressure 
upon the articular nerves. In the case of Mr. Collinson, also mentioned 
by Mr. Cooper, a surgeon, who saw the patient immediately after the 
accident, failed to discover the true nature of the injury ; and Trow- 
bridge's patient had suffered a dislocation several weeks before the nature 
of the accident was fully determined. In a patient of Sedillot's, Du- 
puytren, who was first consulted, thought it was a simple inflammation 
of the joint: and Nelaton related to Panas in 1870, three errors in 
diagnosis committed by surgeons of merit in connection with this 
accident. 

Prognosis. — In B. Cooper's case the arm was not reduced, and never 
recovered any considerable degree of usefulness. Sebilleau reports a case 
in which the reduction having been attempted fifteen days after the acci- 
dent, proved unsuccessful. Three months later the attempt at reduction 
was repeated by Richet, at Hotel Dieu, but without success; and at the 
end of four years the arm was nearly immobile, the muscles of the fore- 
arm and hand being much contracted. 

Tillaux's patient, aet. 59, having a dislocation of six years' standing, 
which being reduced could not be maintained in place, had but limited 
use of his arm. Elevation of the arm was impossible. In Schmidt's 



732 DISLOCATIONS OF THE SHOULDER. 

case, tlic dislocation Mas of eighteen years' standing, and the motions of 
tlif arm wore almost completely restored. 

Mr. Colli nson's arm, reduced on the second day, was restored to all its 
functions within one month. Dr. Parker's patient had nearly recovered 
the complete use of her arm at the end of four weeks, although it was 
not reduced until it had been out fourteen days. Sedillot succeeded in 
reducing the dislocation in the case of his patient, at the end of one year 
and fifteen days. Lepelletier, after forty-five days. Trowbridge, after 
forty days; and in this latter case we are informed that the arm was 
restored to usefulness. 

Treatment. — In the first case mentioned by Sir Astley Cooper, "the 
bandages were applied in the same manner as if the head of the hu- 
merus had been in the axilla, and the extension was made in the same 
direction as in that accident" (downwards and a little outwards). In 
less than five minutes the bone slipped into its socket with a loud snap. 
The second case was treated successfully in the same way. Mr. Dunn 
also having failed to reduce by pulling upwards, finally succeeded by 
pulling at the wrist downwards and forwards, while an assistant pushed 
the head of the bone toward the socket; the heel was not placed in the 
axilla, which Mr. Bransby Cooper thinks would have only retarded the 
reduction. Smith succeeded by a similar manoeuvre. Mr. Key also 
failed to accomplish reduction while carrying the arm upwards and 
backwards, but when the patient had become faint, by placing the 
heel in the axilla and pulling downwards a minute or two, the bone 
was reduced. Vidal (de Cassis) recommends the same plan, namely, 
that Ave shall pull in the direction in which we find the limb ; Trow- 
bridge employed the pulleys successfully, the extension being made 
downwards and forwards; while Dr. Parker succeeded equally well 
with his patient, by "" pulling the arm outwards, downwards, and 
Blightly forwards." Counter-extension was at the same time made by 
a sheet in the axilla, and the head of the humerus was pushed toward 
the socket by the hand. In Mr. Collinson's case, the scapula was 
supported by a towel, while "gradual extension of the limb was made 
directly outwards, and then the arm being moved slowly forwards, 
the head of the bone was distinctly heard to snap into its socket." 
The time occupied was not more than two or three minutes. Rogers 
succeeded by N. R. Smith's method. Sir Astley, however, seems to 
give the ] (reference to the method which succeeded so happily in the 
case of Mr. <;., while lie was still manipulating with a view to determine 
the character of the accident. "I readily reduced the bone," he re- 
marks, "by raising the hand and arm, and by turning the hand back- 
wards behind t lie head." In one other instance, having failed to re- 
duce it by slight extension outwards, he raised the arm perpendicularly, 
at the same time forced it backwards behind the patient's head, and the 
reduction ^a.^ promptly effected. Markham succeeded by a similar 
manoeuvre. In the case of Kretner, I first attempted reduction by pres- 
ume directly upon the head of the humerus; but failing, I proceeded to 
pull the arm with moderate force outwards and downwards, which pro- 
cedure was attended with immediate success. The patient was under 
the influence of chloroform. 



DISLOCATIONS OF THE HUMERUS BACKWARDS. 



733 



Slight forward traction was sufficient in the case of Duplay. Molliere 
combined direct pressure upon the head with slight extension. Arm. 
Despres succeeded by traction made at a right angle with the body, com- 
bined with moderate rotation. 

Prof. Gunn, in describing the specimen from which the accompanying 
illustration is taken, remarked: "It is seen that the head rests on the 
dorsum of the scapula, while the vacated glenoid cavity is covered by the 
anterior untorn half of the capsular ligament, which is stretched across the 
articular surface, holding the head snugly against the posterior edge of 
the fossa, and by its inferior fibres causing the advanced position of the 
lower end of the humerus, which is so characteristic of the accident. 
Internal rotation relaxes this untorn portion of the ligament, as does 
also a still more advanced position of the elbow with the humerus ele- 
vated to a horizontal position. 

u For a reduction of this luxation the shoulder should be properly 
fixed by an assistant, while the surgeon seizes the arm by the elbow and 
forearm, raises it to a horizontal position, carries it to the front, rotates 
inwardly and draws it into place." 1 

After the reduction, a compress should be placed against the head of 
the bone, and underneath the spine of the scapula, and this should be 
secured in its place by several turns of a roller. The forearm ought also 

Fig. 289. 




Showing untorn anterior half of capsule in dorsal dislocation of the humerus. (Gunn). 

to be placed in ;i sling, with the elbow thrown a little back of the centre 
of the body. 90 a- to direct the head of the humerus forwards. 



1 (iunn, loc. cit. 



784 DISLOCATIONS OF THE SHOULDER. 

§ 4. Dislocations of the Humerus Upwards. 
Syn. — •• Sus-Coracoidienne;" Malgaigne. 

A< has already been Btated, the existence of this form of dislocation, 
unaccompanied with a fracture of the coracoid or acromion processes, or 
of both, has been denied by Boyer, Sedillot, and most other surgical 
writers. A certain number of facts and of observations, however, which 
tend to establish its possibility or its actual occurrence, render it neces- 
sary that I should present a risumS of the testimony relating to this 
subject. 

Malgaigne, 1 who was the first to admit of its possibility, writes as 
follows: 

••A man. aet. 68, was seated upon a wagon loaded with fagots, when the 
wagon was overturned. He was thrown a great distance, and struck 
upon the point of the shoulder, with the arm against the side of the 
body. The man immediately experienced a sharp pain, and it was im- 
possible to move the arm. A bone-setter made violent tractions, and 
Bent him away with his arm in a sling. Eight days after he tried to 
move it. hut without much success; and he came to consult me at the 
end of two months and a half. The head of the humerus was dislocated 
forwards and upwards above the acromio-coracoid ligament, correspond- 
ing outwards to the internal border of the acromion, covering inwards 
the coracoid process, and resting above against the inferior surface of the 
clavicle, raising the deltoid muscle to such an extent, that a pin inserted 
into the most projecting part did not show more than eight millimetres 
of flesh; while the pectoralis major and the deltoid were six millimetres 
fin > 1 1 1 the surface. The arm was not shortened more than half a centimetre. 

" I attempted reduction by elevating the arm to a right angle, at the 
same time pressing on the head to push it downwards, outwards, and 
backwards, while an aid tried to press the acromion upwards, inwards, 
and forwards. At J<>o kilogrammes I heard a cracking as if a bone had 
been broken, although the reduction did not seem to have been effected. 
I ceased traction, and explored all the points of the shoulder without 
discovering any fracture. There did not even ensue any sensible tume- 
f;i'-t i<oi. The head was more movable, and it was possible to draw it 
downwards until the fingers could be laid in the space thus created below 
the clavicle. There was also some gain in the freedom and extent of the 
movements. I thought of dividing the acromio-coracoid ligament, but 
after some reflection I judged it preferable not to do so." 

According to Poinsot, similar examples have been reported by Ver- 
neuil, Le Dentu, Busch, Laugier, Chassaignac, and Denonvilliers. 

Ycnc-uil ;md Le Dentu were unable in their patients to find a frac- 
ture of the coracoid process. The same was the fact with Busch; while 
Laugier, Chassaignac, and Denonvilliers are silent upon this subject. 

In the case Been by Busch, 2 a man was driving a horse, when it ran 
away: hut while he was still holding the reins, he seized the bit with 

1 Malgaigne, <>]>. cit., vol. 2. p. 530. 

Lrch. fur Klin., Bd. in, Hft. 3, p. 400. 



DISLOCATIONS OF THE HUMERUS UPWARDS. 735 

his right hand, when the horse rearing struck the shoulder with its foot 
at the antero-internal portion of the scapulo-huineral region. 

In Laugier's case, a lad. 16 years old, having his arm stretched out 
and fixed on a machine, with his body resting on his arm, and his feet 
far from the resting point, felt suddenly a violent torsion of the body 
from before backwards, and from right to left. 

M. Poinsot thus explains the mechanism of the accident in this case : 
"Id that movement, the head of the humerus, on which the body 
rotated, underwent a movement of rotation outwards, being carried at 
the same time upwards and forwards, so as to correspond to the superior 
and anterior part of the articular capsule; which latter being torn where 
it was stretched, the bone was permitted to go upwards, so as to place 
itself outside the beak of the coracoid apophysis/' 

In a case seen by Dr. Holmes, 1 the patient, a man, 60 years of age. 
had fallen a great height (about 30 feet) upon a pile of stones, striking 
upon the head, the left side of the body, and the left elbow. When 
brought to St. George's Hospital, his unconsciousness, indicating cere- 
bral concussion, rendered it necessary to postpone the reduction for 
several days. When it had been decided to attempt it, he was taken 
with septicemic symptoms, which originated in a compound fracture of 
the elbow, and he died fifteen days after the accident. 

On examining the dislocated shoulder, the head of the humerus was 
found immediately under the skin, with the cephalic vein at its internal 
portion. It had fractured the coracoid apophysis in its movement from 
below upwards, and was resting behind on the projection of that apophy- 
sis and on the clavicle, pulling with it a small portion of the acromio- 
coracoid ligament which had not been torn. At its internal portion, 
beside a few fibres of the deltoid and of the cephalic vein, the fractured 
extremity of the coracoid process was found, with the muscles which are 
inserted in it : the pectoralis minor, the coraco-brachialis, and the short 
portion of the biceps. At the external portion and a little backwards 
was the acromion, separated from the head by a few fibres of the deltoid. 
Below and a little outside was the glenoid cavity, whose superior border 
was situated entirely below the level of the humeral extremity. The 
tendon of the longer portion of the biceps was still attached to the 
scapula, and was consequently situated below and outside of the dislocated 
head, which, as it came out of its socket, had slightly torn this tendon. 
so that a few of its internal fibres had been separated from the muscle 
and remained floating freely, with a cluster of muscular fibres attached 
to them. The coracoid apophysis had been fractured near its base, the 
'-acromial ligament remaining attached to the two fragments so 
that they could not be much separated from each other; the summit was 
pulled from above downwards, and from out inwards, by the muscles 
inserted in it. The humeral head rested directly on the projection of 
the apophysis, which had produced a slight erosion on the corresponding 
articular cartilage. The humerus had slightly turned mi its axis, so that 
the greater tuberosity was relatively more in front than in its normal 
position. The subscapulars muscle was intact. The muscles inserted 

1 II ■< "hir. Trans., vol. 41. 



786 DISLOCATIONS OF THE SHOULDER. 

into the greater tuberosity had been lac-orated, except a portion of the 
tores minor, which had remained uninjured: the capsular ligament, torn 
at its superior and internal portion, presented a large opening which had 
given passage to the head. 

Albert, 1 of [nnsbriick, has reported a case of double dislocation upwards, 
in a man »><) years old. which had existed many years. This man having 
died of pneumonia, an autopsy was obtained. All that was known about 
the origin of the dislocation was, that it was caused while he was trying 
to hold a pair of spirited horses by the bridle. 

The following condition of the parts was found at the autopsy : 
"Left Shoulder. — After the removal of the skin, the great pectoral 
muscle was seen gathered on itself, from below upwards, so that its ver- 
tical diameter, on a level with the mammary line, was ten centimetres 
long : the fandike direction of its fibres, at the level of its insertion being 
consequently far more noticeable than in the normal state. The deltoid 
was very much stretched in its middle part, and was relaxed, on the 
contrary, in its scapular portion. In the movements of slight abduction, 
the great pectoral and the teres major muscles were stretched and resisted 
the effort. The deltoid being detached at its inferior insertion, a small 
independent subdeltoid bursa was found ; the subacromial bursa, situated 
more backwards and small, presented on its internal surface papillary 
vegetations. After removing the great pectoral, at the inner side of the 
humerus, the coraco-brachialis and the smaller portion of the biceps were 
found intact, as well as the plexus and the vessels which were also sit- 
uated at the inner side of the bone; the tendon of the longer portion of 
the biceps could be followed to the inferior limit of the surgical neck, 
where there existed a bony prominence, which we shall mention further 

Fig. 290. Fig. 291. 





Albert's case of double upward dislocation. 
Front view. Side view. 

"ii : hut the tendon ended there by a sort of swelling; the bicipital 
groove was uo more distinguishable. The capsule, of medium thickness, 
was inserted into the whole circumference of the anatomical neck; on a 

1 Albert, Wiener Med. Clutter, 1879, 19, S. 453. 



DISLOCATIONS OF THE HUMERUS UPWARDS. 737 

level with the humeral head it adhered also to the articular surface ; 
looking downwards and backwards to its central insertion, the capsule 
presented in front and above a considerable enlargement of its cavity 
so as to touch the lateral part of the coracoid apophysis, and it was 
attached to the edge of the acromio-coracoid ligament. The acromio- 
coracoid, the trapezoid, and conoid ligaments were intact. The humeral 
head overlapped, by its superior third, the edge of the acromio-coracoid 
ligament, but could easily be pushed upwards, into the space comprised 
between that ligament, the acromion, and the coracoid processes, so as to 
overlap the ligament by all its superior half when the humerus was car- 
ried outwards and backwards. The glenoid cavity was filled with cellular 
tissue, which on a level with the margin presented a highly polished 
surface. From the inferior edge of the surgical neck to the head of the 
humerus, was a bony lamella, starting from the postero-lateral part of 
the bone and terminating backwards by a very irregular free edge. From 
the base of the coracoid apophysis a very nodulated bony prominence 
was detached, its shape being that of a crow's beak, or rather a deer's 
horn, and measuring two centimetres and a half in length. 

"Right Shoulder. — The muscles, the large vessels, the acromio- 
coracoid, conoid, and trapezoid ligaments, as well as the scapula and the 
humerus, were all in their normal state. The acromial extremity of the 
clavicle was enlarged, with a flattening of the portion corresponding to 
the head. The capsule presented the appearance of a large sac with 
walls very much thickened at certain points. In the part corresponding 
to the superior margin of the glenoid cavity were a number of superposed 
horizontal folds, of the size of a centimetre, and projecting into the 
interior of the cavity ; these folds divided it into two portions, an inferior 
one, corresponding to the old articular cavity, and a superior one, cor- 
responding to the new one. The head could be abnormally moved in all 
directions within the capsule, and it appeared flattened above and behind 
and was denuded of its cartilage. On the level of the anatomical neck, 
the cartilage was worn out in places ; in others it presented a velvety 
alteration, at which points it was of a yellowish-gray color. The bicipital 
groove was very shallow." 

Panas and Angers 1 have demonstrated upon the cadaver that the head 
of the humerus could be dislocated upwards above the acromio-coracoid 
vault without destroying it. 

It may be here stated briefly, by way of summary, that the testimony 
which is to establish the possibility of this accident, unaccompanied with 
a fracture, is found in seven clinical cases not verified by an autopsy, in 
certain experiments made upon the cadaver, and in the single case re- 
ported by Albert, and demonstrated by a dissection. 

With the imperfect knowledge in my possession relative to the purely 
clinical cases, I am not warranted in subjecting them to criticism. As 
to the value of* Panas's experiments made upon the cadaver, I must re- 
peat what I have often said before in reference to similar experiments 
made upon other joints. The results of such experiments cannot be 
applied without great reserve, to dislocations occurring upon the living 

1 Panas, Art. Epaule, Nouveau Diet, de Sled, et de chir. prat., t. L3, p. 466. 



738 DISLOCATIONS OF THE SHOULDER. 

subject, and when the muscles have their normal power and activity. Of 
the case of the man Bet. 60, reported by Albert, and in which case alone 
has a dissection revealed a dislocation without a fracture, the fact that it 
existed in both Bhoulders at the same time, connected with the obscurity of 
its history, BUggest the possibility that, instead of having been primarily 
a dislocation, it was at first only a sprain, from which resulted an arthritic 
and muscular affection, in consequence of which latter conditions the 
displacement had gradually been produced. 

The following remarks are quoted from Poinsot, who accepts the dis- 
location as an established fact: 

"Prognosis. — In all cases of absolutely recent dislocation, and where 
reduction has been effected without great efforts, the prognosis is possessed 
«»f little gravity : but it soon becomes very serious both on account of the 
extreme hindrance resulting from the persisting displacement, and of the 
infinite, if not insurmountable difficulties which are met with during the 
attempts at reduction after a certain lapse of time. Laugier, on the 
twelfth day, could not reduce the dislocation in his patient; Malgaigne 
after two months and a half, and Busch after five months, were also 
unsuccessful. Professor Verneuil, it is true, was able to effect reduction 
on the thirty-sixth day, but it was a dislocation which had already been 
reduced on the very day of the accident, and which had been repro- 
duced. 

u Treatment. — Malgaigne, in the case of his patient, had attempted 
reduction by making tractions upon the arm elevated at a right angle, 
and by pressing upon the head in such manner as to push it downwards, 
outwards, and backwards, while an assistant tried to pull the acromion 
upwards, inwards, and forwards. Busch employed, without being more 
successful, Scliinzinger's procedure (rotation outwards), and that of A. 
Cooper, elevation of the arm at different degrees. Denonvilliers and 
M. Verneuil effected reduction by means of tractions downwards, com- 
bined with a tilting motion with the view r of bringing back the head 
toward the cavity. M. Verneuil had failed the first time, when tractions 
downwards were made alone, and, during his second attempt, he thought 
it necessary to anaesthetize the patient. 

■• M. Panas, being guided by experiments, advises 'to carry the arm 
away from the body until the head is sufficiently lowered to pass under 
the coracoid ; at the same time that the elbow is being raised, it is neces- 
Bary to ^\w the humerus a movement of rotation inwards, gradually 
increased.' Albert, of [nnsbriick, recommends abduction, extension 
backwards, and rotation inwards. 

" Verneuil, in order to prevent the dislocation from being reproduced, as 
had already happened twice, placed the arm (strongly adducted) in front 
of the chest, the hand being placed upon the sound shoulder, and main- 
tained it in that position by means of a silicate bandage." 

\ 5. Partial Dislocations of the Humerus. 

Sir Astley Cooper has related in his treatise two cases of supposed 
incomplete dislocation of the head of the humerus forwards; and in con- 
firmation of hie news Ik- has added an account of the appearances pre- 



PARTIAL DISLOCATIONS OF THE HUMERUS. 739 

sented on dissection in the body of a subject brought into the rooms of 
St. Thomas's Hospital. Bransby Cooper, in his edition of the same 
work, furnishes the report of a similar case which came under the ob- 
servation of Mr. Douglass, of Glasgow. Hargrave and Dupuytren have 
each reported one example of this species of dislocation, in which its 
existence was said to be confirmed by dissection. 

Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and 
many others, have admitted its possibility; Malgaigne, however, only 
admits its existence when the capsule remains entire. 

Without intending to discuss very much at length the value of these 
opinions, I shall content myself with declaring that the existence of this 
or of any other form of partial dislocation of the shoulder-joint, as a 
traumatic accident, has not up to this moment been fairly established ; 
and that the anatomical structure of the joint renders its occurrence 
exceedingly improbable, if not absolutely impossible. 

The only example mentioned by Sir Astley Cooper, in which a dis- 
section was made, showed that the long head of the biceps had been 
ruptured, and that the capsule was torn, while the head of the humerus 
was resting under the coracoid process. We shall have no difficulty, 
therefore, in assigning it to its proper place as a complete subcoracoid 
dislocation. In Mr. Hargrave's case, also, the tendon of the biceps was 
torn ; while Dupuytren omits to mention what was the actual fact in 
relation to this tendon in the case seen by him, but it is distinctly stated 
that the head of the bone rested upon the ribs. Mr. Hargrave seems, 
therefore, to have described a case of rupture of the long head of the 
biceps, and it is probable that Dupuytren, who knew nothing of the 
previous history of the subject, has given us a- faithful account of a 
pathological dislocation, a result of disease, and not of a direct injury. 
Poinsot remarks, also, that the four cases mentioned by Owen 1 were 
examples of chronic lesion. 

If the head of the humerus is driven from its socket by violence, and 
remains thus displaced, it is, I assume, a complete dislocation ; since it 
is only by having placed the semi-diameter of the head of the bone out- 
side of the margin of the glenoid fossa that it can be made for one 
moment to retain its abnormal position. To accomplish this amount of 
displacement upwards, or upwards and forwards, or directly forwards, the 
acromion or the coracoid process must, as I think, be broken ; while its oc- 
currence in any other direction must involve at least a most extraordinary 
extension, if not an actual laceration, of the capsule. If we admit, with 
Malgaigne, that occasionally the capsule has been found capable of such 
extraordinary extension without actual rupture, I am still unwilling to 
regard this as a fair example of a partial dislocation, since the head 
of the bone no longer moves in its socket, being at no point in actual 
contact with the articular surface of the glenoid fossa. It is essentially 
a complete dislocation, according to all the admitted definitions of this 
term. 

It is quite probable that a majority of these accidents were examples 
of rupture or displacement of the tendon of the long head of* the biceps, 

1 E. Owen, The Lancet, 1*75, vol. i. p. 759. 



740 



DISLOCATIONS OF THE SHOULDER. 



the effect of which, as Mr. John <». Smith 1 and Mr. Soden 2 have shown 
by a Dumber of dissections, is to allow the head of the humerus to be 
drawn upwards and forwards in its socket, until it is arrested by the two 
processes, and by the coraco-acromial ligament. Says Mr. Soden: "To 
enable the hone to maintain its equilibrium, it is necessary that the cap- 
sular muscles should exactly counterbalance each other; and as there is 
no muscle from the ribs to the humerus to antagonize the upper capsular 
muscles" (thai is, to draw the head of the humerus downwards), "it is 
suggested that this office is performed by the singular course of the long 
tendon of the biceps, which, by passing over the head of the bone, when 
the muscle is put in action, tends to throw the head downwards and back- 
wards: it follows, therefore, that, the tendon being removed, the head of 
the bone would rise upwards and forwards." 

Fig. 292 represents the case of displacement of the tendon of the 
biceps seen by Mr. Soden, and of which he was permitted to make a 
dissection. 3 

I have myself frequently observed, and I have before, when speaking 
of the prognosis or results of dislocations, called attention to the fact, 

that the head of the humerus some- 
times remains for a long time after the 
reduction has been effected slightly 
advanced in its socket, so as to lead to 
a suspicion that it is not properly re- 
duced. Quite recently I have been 
consulted in the case of a lad about 
fourteen years of age, who had been 
subjected to the pulleys during four 
consecutive hours to accomplish a 
more complete reduction. 

The same thing, also, has been no- 
ticed by me occasionally where the 
shoulder had been subjected to a vio- 
lent wrench, but no actual dislocation 
had ever occurred. In either case the 
explanation is perhaps the same, the 
long head of the biceps has been 
broken or displaced; or. when it follows a dislocation, some of the 
muscles inserted into the greater tuberosity have been torn from their 
attachments. I mean to Bay, that in these circumstances we may find a 
sufficient and perhaps the most frequent explanation; yet it is quite 
probable that, in a considerable number of cases, the laceration of the 
capsule, and the action of the muscles, are alone concerned in the pro- 
duction of tlii> phenomenon. I have seen one example in the person of 
Mr. Craig, of Brooklyn, in which the tendon of the biceps suddenly re- 
Bomed its position after the lapse of several days, and the prominence of 
the head of the humerus at once disappeared/ David Prince, 4 Hewitt, 5 

A.mer. Journ. Med. Sei., vol. wi. p. 219, May, 1835, from London Med. Gaz. 
- [bid., v<.l. mix. p. |so. from Lond. Med. Gaz., July, 1841. 
■ Pirrie'a System <>r Surgery, A.mer. ed., p. 255; also, Sir Astley Cooper, edited 
by Bransby Cooper, Amer. ed., p. '■)>',■',. 
* Prinr<-. St. Louifl Med. and Surg. Journ., Nov. 1*70. 
5 Hewitt, Holmes's Surgery, 2d Lond. ed., vol. ii. p. 820. 




Displacement of the long head of the biceps. 



PARTIAL DISLOCATIONS OF THE HUMERUS. 741 

and Holmes 1 have reported similar eases. In Mr. Holmes's case, how- 
ever, the eoraeoid process was broken also. 

Alfred Mercer, of Syracuse, X. Y., in a very interesting paper on 
this same subject, relates several examples of forward displacement after 
injuries to the shoulder-joint, one of which, as being exceedingly perti- 
nent. I shall take the liberty of quoting : 

"Mrs. B.. a well-developed woman, of full habit, aged fifty-six, seven 
years since was thrown from a carriage, dislocating her right shoulder, 
which was reduced a short time after the accident, but the shoulder was 
painful, and tender to the touch, and almost useless for months after. 
She could carry the arm forwards and backwards, but could not raise it 
from the side, or carry her hand behind her, or raise it to her head, for 
fourteen months. She has gradually gained better use of her arm, but 
now. July. 1858, she cannot raise her elbow from the side more than 
half-way to a horizontal position without assistance ; but with assistance, 
the arm may be carried into any position without pain or resistance. 
Measurement shows no appreciable difference in the size or length of the 
arm. or size of the shoulder: but the point of the shoulder is still tender 
to the touch, is prominent in front, and correspondingly flattened behind. 
The head of the humerus appears to rest against the outside of the 
eoraeoid process, but the fulness of habit obscures the diagnosis, com- 
pared with other cases. Several doctors, at different times, have ex- 
amined the shoulder ; some have said it was not properly reduced, and 
advised a suit for malpractice. 

* ; I examined the shoulder again in November last; it presented the 
same general appearance, although the patient was much thinner in flesh 
from recent sickness. Some six weeks previous to this examination, 
in a sudden and thoughtless effort to raise the arm above the head, the 
muscles unexpectedly obeyed the will ; since which time she has had 
perfect use of it, though the deformity still remains. She thinks she 
felt or heard a snap when the arm went up, but it was followed by no 
pain, soreness, or swelling." 2 

There cannot be much doubt, I. think, that in this case, at least, the 
deformity and maiming were due in a great measure to a displacement 
of the long head of the biceps. 3 

If a displacement of the tendon necessarily causes a displacement of 
the head of the humerus, it might seem proper to infer that a rupture 
of the tendon would do the same. The only example of rupture of the 
tendon which has come under my observation does not confirm this 
opinion. 

James Wallace, aet. 4'!. a Bailor, and a man of remarkable muscular 
development, while pushing a swing with his arms extended felt some- 
thing snap in his right arm. and the arm at once became powerless. 
The sensation of snapping was at a point about four and a half inches 
below the acromion process. The pain was like that caused by hitting 
a nerve: on the following day there was an extensive ecchymosis over 

1 Holmes's Surgery, 2d Lond. ed., vol. ii. p. 820. 

- Bfercer, Buffalo lied. Journ., vol. xiv. p. 641, April, 1859. 

3 Broom field's Chirurg. Observ., vol. ii. p. 76. 



74:2 DISLOCATIONS OF THE SHOULDER. 

the upper end of the humerus, and the belly of the biceps was full and 
flabby. 

Wallace was examined by me at Bellevue Hospital in March, 1875, about 
eighl months after the injury was received. The belly of the biceps 
had shortened upon itself, and made a very remarkable prominence on 
the front of the arm, but he could not render it firm by contraction. He 
could flex the arm slowly, but not against any considerable resistance. 
The head of the humerus was not advanced in the socket. I could feel 
the tendon of the biceps in its groove, and inferred that the rupture took 
place near its insertion into the muscle. 

J. L. Petit has reported a similar case, in which the rupture was 
caused by the extension employed in an attempt to reduce a dislocation 
of the arm. 1 

Poinsot records an example of rupture of this tendon in a man, caused 
by lifting, and in which the head of the humerus was not displaced. 
Three weeks later the same accident was reproduced in a similar manner, 
and Poinsot remarks that the phenomena presented were the same as in 
Wallace's case. 

Dr. Arpad G. Gerster, in a paper read before the Society of the Phy- 
sicians and Surgeons of the German Hospital and Dispensary of New- 
York, Oct. 12, 1877, on " Subcutaneous Injuries of the Biceps Brachii,'* 2 
lias made some historical notes and observations wdiich seem deserving a 
place in this connection. He says: "Older surgeons (Stanley, Brom- 
field, Knox, Monteggia, for instance), up to the middle of this century, 
diagnosed as dislocations of the long head of the biceps, cases similar to 
the one related" (case of partial rupture of the tendon, and of the corre- 
sponding part of the sheath of the long head of the biceps). " They 
supposed that the tendon left rts groove, and slipped upon the major 
tubercle. True, none of them ever found the tendon in its dislocated 
condition, but they assumed that a spontaneous reduction took place by 
a rotation of the humerus, before a competent judge could ascertain the 
nature of the injury. AVilliam Cooper and Boerhaave acepted the pos- 
sibility of such an injury. Fergus^on expressed himself cautiously on 
the subject. Bardeleben, Pitha, and Volkmann deny its existence, refer- 
ring to a series of exhaustive articles in the Gf-azette Hebdomaclaire 
(2d ser., iv. [xiv.], 21, 23, 25, 1867), written by Jarjavay, which com- 
pletely disposes of this 'mysterious dislocation,' as Pitha sarcastically 
call- it."' 

Gerster states, moreover, that Pouteau had long before doubted the 
existence of this dislocation, and that Malgaigne had expressed scepti- 
cism as to the true character of Mr. Soden's case. In short, Dr. Gerster 
claims that its existence, uncomplicated with other accidents, has never 
been demonstrated satisfactorily upon the living or dead subject; and 
that, to say the least, it is doubtful whether it has ever occurred. The 
entire argument, together with the anatomical reasons assigned, are very 
ingenious; and while they do not settle conclusively in my own mind 
the question of it- possibility, they seem to throw a doubt upon the true 
nature of some of the cases reported. 

1 Malgaigne, op. cit., Paris ed., 1855, vol. ii. p. 145. 
<■ X. V. Vied. Journ., May, 1878, p. 487. 



DISLOCATIONS OF THE HEAD OF THE RADIUS. 743 

Dr. White, 1 of Philadelphia, in an excellent resume of this subject. 
concludes that the occurrence of a traumatic dislocation of the long- 
tendon of the biceps, unaccompanied with a dislocation of the humerus, 
has not been absolutely proven. He reports, however, a case which both 
Dr. Agnew and himself believed to be such a dislocation. A man, aet. 
•i)7. had fallen upon his shoulder from a considerable height. Seen by 
these surgeons soon after the accident, it was thought that the empty 
bicipital groove and the displaced tendon could be distinctly felt. At 
the end of two years the displacement continued, and at this period the 
patient had recovered nearly, but not wholly, the free use of his arm. 



CHAPTEK VIII. 

DISLOCATIONS OF THE HEAD OF THE RADIUS 
(HUMERO-RADIAL). 

I have recorded thirty-two examples of traumatic dislocation of the 
head of the radius as having been seen and examined by me ; of which 
twenty-seven were dislocated forwards, or forwards and outwards, and 
only five backwards : or, rejecting those cases which were complicated 
with fracture, I have recorded fourteen cases of simple forward disloca- 
tion, and three of simple backward dislocation. My experience, there- 
fore, does not correspond with the experience of Boyer, Velpeau, Vidal 
(de Cassis), Chelius, B. Cooper, Guthrie, Gibson, and some others, who 
declare that the dislocation backwards is the more frequent of the two. 
Indeed, I ought to say of two of the examples of backward dislocation 
of the radius which have come under my notice, and which I have 
marked as simple, that they were ancient dislocations ; and I am not 
entirely certain, therefore, that they had not been originally complicated 
with a fracture, although at the time of my examination they presented 
no such evidence. The third, which I believe to have been a genuine, 
simple backward dislocation, I will mention again in connection with 
this latter form of dislocation. I have seen one congenital dislocation 
of the head of the radius outwards and forwards, which I will describe 
more particularly in the chapter on Congenital Dislocations. 

\ 1. Dislocations of the Head of the Radius Forwards. 

Causes. — A fall upon the elbow, the blow being received directly upon 
the posterior face of the head of the radius; a fiill upon the baud with 
the forearm extended and pronated; extreme pronation of the forearm ; 
or. according to Denuce, a blow upon the inside of the elbow, which is 
equivalent to a violent adduction of tin- forearm. 

1 'White. J. TV.. Surgeon to the Philadelphia Eospital, and Asst. Surgeon to the 
University Hospital. Amer. Journ. Med. Sci , Jan. l v H. 



744 DISLOCATIONS OF THE HEAD OF THE RADIUS. 

In children, and especially in those of a strumous habit, -whose liga- 
ments are feeble, a subluxation forwards, or even a complete disloca- 
tion, is occasionally produced by being lifted suddenly from the floor by 
the hand, or by an attempt to sustain the child when he is about to fall. 
I haw seen examples of this dislocation produced in this way. Batch- 
elder, 1 Sylvester, 2 Goyrand, a and many other surgeons, have mentioned 
similar cases. In the case of Lydia Merton, four years old, brought to 
me in May. 1868, the dislocation was caused by holding on by the hands 
utter having fallen from a swing. 

Dr. Krackowizer related to the New York Academy, in 1856, a case 
of complete dislocation forwards, produced, as was supposed, in the act 
of turning the child in delivery. The arm was ecchymosed, and the 
dislocation was very distinct. 4 

Leisrinck 5 saw an ancient dislocation forwards in both arms, which 
were said to have been produced immediately after birth by violent tor- 
sion of the forearms, practised for the purpose of resuscitating the child. 

Pathological Anatomy. — The head of the radius is carried forwards 
upon the humerus, and generally a little outwards. In the case of Lydia 
Merton, already mentioned, the head of the radius, on the ninety-fourth 
day after the accident, was nearly in the centre of the humerus. The 
anterior and external lateral ligaments, with the annular, are in most 
cases more or less broken. Sometimes the anterior and external lateral 
are alone broken, the annular ligament being then sufficiently stretched 
to allow of the complete dislocation ; or the anterior and annular having 
given way. the external lateral may remain intact. 

In the specimens dissected by Danyau 6 and Debruyn," and also in the 
specimen deposited by Prestat 8 in the Dupuytren Museum, the annular 
ligament was not torn. In a specimen obtained by J. Hilton, 9 this liga- 
ment was only partially torn. In each of these latter cases the head of 
the radius had formed for itself a new socket on the front of the humerus. 
The -nine Is the fact in a specimen represented by Kronlein, and con- 
tained in the Pathological Museum at Zurich, so that the movements of 
pronation and supination were completely restored. 

Symptoms. — The head of the radius can in general be distinctly felt in 
it- new situation, rotating under the finger when the hand is pronated and 
Bupinated ; we may sometimes also recognize a depression corresponding 
to its natural situation, behind and below the little head of the humerus. 
The external border of the forearm is slightly shortened, and the arm 
incline- unnaturally outwards. The tendon of the biceps is relaxed. 
The forearm is generally pronated, sometimes it is in a position midway 
between supination and pronation, but I have never seen it supinated. I 
have particularly noticed this fad in my report made to the New York 
State Medical Society in 1855; and Denuce, who has also examined 

Batch Ider, New York Journ. MM , May, 1856, p. 333. 
- Sylvester, Amer. Journ. Med. Sci., vol. xxxi. p. 206, Jan. 1843. 

rand, [bid., vol. xwii. ]>. 228, July, 1843. 
; Krackowizer, X<-\\ York Journ. Med., .March, 1857, p. 262. 
rinck, Deute. Zeitschrift fur Chir., Dec. 12, 1873. 
Poinsot, op. cit., ]». - ' Ibid. 8 Ibid. 

1 Hilton. Bull. Gten. de Therap., t. :;8. 1850, p. 113. 



DISLOCATIONS OF HEAD OF RADIUS FORWARDS. 



745 



these cases carefully, affirms that it is seldom supinated, notwithstanding 
the general statements of surgeons to the contrary. 

The arm is usually a little flexed, and cannot be perfectly extended 
without causing pain. In some cases, especially when the dislocation has 
existed for a considerable length of time, the arm is capable of extreme 
and unnatural extension. This was the case with Lydia Merton. There 



Fig. 293. 



Fig. 294. 





Head of the radius forwards, 
relations. 



Head of the radius forwards. External ap- 
pearance of limh. 



is usually preternatural lateral motion ; but, except in old cases, the 
forearm cannot be flexed upon the arm beyond a right angle. 

Prognosis. — Denuce says: "The reduction is often impossible; more 
frequently still, difficult to maintain." In proof of which he refers to 
the observations of Danyau and Robert. In the case of recent disloca- 
tion related by Robert, it was found impossible to maintain a reduction 
which he thought he had several times accomplished, and he believed 
that the difficulty consisted in a portion of the torn annular ligament 
having become entangled between the head of the radius and the con- 
dyle of the humerus. 1 

Sir Astley Cooper was unable to accomplish the reduction in two 
recent cases: and of the six cases which came under his immediate ob- 



M£moire surles Luxation- du Coude, par Paul Denuc€. Paris, 1854. 



74d DISLOCATIONS OF THE HEAD OF THE RADIUS. 

servation, only two were ever reduced. In Bransby Cooper's edition of 
Sir Astley's work, other Bimilar examples of non-reduction are related. 

Malgaigne Bays that in a collection of twenty-five cases which he has 
made, the accident was unrecognized or neglected in six, and ineffectual 
efforts at reduction had been made in eleven; so that only eight of the 
whole Dumber were reduced. 

T have myself met with six of these simple dislocations which were 
not reduced, three of which, however, had not been recognized, and no 
attempt at reduction had ever been made; one had been treated by an 
empiric. Sweet, a ••natural bone-setter," but without success; one had 
been reduced, but it had become redislocated, and in the remaining exam- 
ple I was unable to reduce the dislocation on the seventh day. 

The following are brief notes of four of these cases: 

A young man, set. 23, presented himself at my office, to whom the 
accident had occurred about one year before. The surgeon who was 
first called did not recognize the dislocation, and no attempt had ever 
been made to replace the bones. The forearm was forcibly pronated 
and could not be supinated, but he could extend it completely, and flex 
it somewhat beyond a right angle. It was strong, and nearly as useful 
as before. 

H. H. B., ret. 6 ; dislocation produced by a fall upon the elbow. 
The surgeon who was called did not detect the nature of the injury. 
Eighteen years after, I found the head of the radius lying in front of 
the old socket, having formed a new socket, in wdiich it moved freely. 
From the elbow to the hand the arm inclined outwards, or to the radial 
side: pronation and supination were perfect. He could flex the arm to 
an acute angle, but not so completely as the other. The arm was as 
strong as the other, but it was frequently hurt by lifting. 

Ira E. Irish, xt. 12, had a dislocation of the head of the radius for- 
wards. Sweet, who is mentioned above, was at first employed, but failed 
to reduce it. Thirty-nine years after, when Mr. Irish was fifty-one years 
old. I examined the arm. He could not flex the forearm upon the arm 
beyond a right angle; and when the attempt was made, the radius 
struck against the humerus. Complete supination was impossible. The 
arm was as strong as the other, except in raising a weight above his 
head. Occasionally he was annoyed with slight pains in this limb. 

(Jrias Lett, a colored barber of Buffalo, aged forty-eight years, was 
thrown from a carriage, producing a dislocation of the right radius, and 
severely bruising the elbow-joint. He did not see a surgeon until six hours 
had elapsed. The elbow was then much swollen, and exquisitely tender, 
and Lett would not permit much, if any, examination to determine its con- 
dition. The doctor applied simple dressings, and the next day requested 
me to see him. The whole arm was then swollen and tender, and very 
little examination was admissible The dressings were, therefore, not 
completely removed, hut only laid open sufficiently to enable us to see the 
j"iiit. We suspected ;i forward dislocation of the head of the radius, but 
could not positively determine the point — the patient not permitting any 
kind or degree of manipulation. We decided, therefore, to wait a few 
days until the inflammation had somewhat abated, and then, if the ex- 
istence of a dislocation was ascertained, to attempt its reduction. On 



DISLOCATIONS OF HEAD OF RADIUS FORWARDS. 747 

the seventh day the swelling had measurably subsided, and the diag- 
nosis became satisfactory. We immediately placed him under the com- 
plete influence of chloroform, and made long-continued and violent 
efforts at reduction, but without success. Severe inflammation again 
followed these efforts, and Lett would never consent to another trial. 
After four years I find the bone still out. He can flex the forearm 
upon the arm almost as far as he can the opposite limb ; he can carry it 
nearly to his mouth, the head of the radius sliding off upon the outer 
face of the humerus, and not resting plumply against it; indeed, the 
radius seems to have been gradually pushed outwards as well as for- 
wards. The hand is forcibly pronated, and cannot be supinated. The 
attempt to supine produces a click in the neighborhood of the head of 
the radius, as if it struck against a bone. The arm is as strong as the 
other, and not wasted. He has constantly pursued his occupation as a 
barber, after only a few weeks' confinement. 

If the dislocation is accompanied with a fracture of the ulna, unless 
the fracture is transverse or incomplete, reduction is not generally ac- 
complished. When speaking of fractures of the shaft of the ulna. I 
have related several examples illustrative of this remark. Norris has 
made the same observation. 1 I have, however, three times met with 
this accident thus complicated in children, in the treatment of which a 
much better result has been obtained. In the first example, a lad, aged 
nine years, had broken the ulna in its upper third and dislocated the 
radius forwards. Dr. White, of Buffalo, and myself were in immediate 
attendance. Both the fracture and dislocation were easily reduced, and 
in a few weeks the limb was sound and perfect, except that a slight 
fulness remained in front of the head of the radius, and this continued 
for several years. In the second example, a lad, of the same age as the 
other, was treated by Dr. Austin Flint and myself. We reduced both 
the fracture and the dislocation by extending the arm from the wrist, 
while at the same moment pressure was made upon the head of the 
radius from before backwards. A right-angled splint was applied and 
continued during a period of four weeks, being removed daily for the 
purpose of giving to the joint gentle, passive motion, etc. After this 
the arm was permitted to straighten gradually, and at the end of a 
month more the joint was moving freely, and with no degree of displace- 
ment at the point of fracture or dislocation. 

It is quite probable that in each of the above cases the separation was 
not complete, although crepitus was distinct, and the displacement of the 
broken ends was very marked. In the following case the fracture was 
certainly incomplete : 

Elizabeth Carmody, aet. 4. was brought to me. August 6, 1851, with 
a fracture of the ulna, two inches below its upper end. the fragments 
being inclined backwards, while the radius was dislocated forwards. 
Both l>on<-s were easily replaced, and the functions of the arm were 
soon completely restored. This case was erroneously reported t<» the 
Medical Society as an example of fracture of the radius, 
with dislocation. 

1 N M S rol. xxxi. p. 21. 



748 I- IS LOCATIONS OF THE HEAD OF THE RADIUS. 

Where the restoration has been promptly effected and maintained 
steadily, the motions of the joint are soon restored; but in one case the 
head of the radius lias been found to play very freely and loosely after 
the lapse of two years, and in others it lias remained slightly prominent 
in front, as if it was a little in advance of its socket. 

Treatment. — Kxtension and counter-extension should be made in the 
direction in which we already find the limb, namely, with the forearm 
slightly bent upon the arm, while at the same moment the surgeon should 
seize the elbow with his hands, and press the head of the radius back 
with his two thumbs. 

Other methods will often succeed; but by this we relax the biceps, 
and put the parts in the best position to accomplish the reduction easily 
and promptly. Sir Astley directed to supine the forearm while the 
extension was being made from the hand, but Denuce prefers that the 
forearm should be in a position of pronation. 

After the reduction is effected it is never safe to straighten the arm 
completely at once, nor indeed for some weeks; not until the ligaments 
have been sufficiently restored to resist the action of the biceps. The 
arm must, therefore, be flexed and placed in a sling, or, if the radius is 
disposed to become redislocated, a right-angled splint ought to be placed 
upon the back of the arm and forearm, and, by the aid of a compress 
ami roller, an attempt should be made to retain it in place. 

Ne* will it be found safe at any period to compel the arm by force 
to resume the straight position, since this bone, when it has once been 
dislocated, will for a long time be liable to dislocation. 

A boy. aged about four years, was presented at my clinic by his 
father, having a forward dislocation of the head of the radius. The dis- 
location had existed several months. The father's purpose in bringing 
the child was to ascertain whether he could not claim damages for mal- 
practice. The account which he gave was as follows: The surgeon 
called it a dislocation forwards, and pretended to reduce it. A right- 
angled splint was applied with a roller. At the end of three weeks the 
father removed the splint, but did not discover anything out of place. 
Finding, however, that the elbow was stiff, he took measures to straighten 
it forcibly. In a few days he discovered the head of the bone out of 
place, and so it has remained ever since. 

I explained to him that there was much reason to suppose that the 
surgeon had properly reduced the dislocation, and that he had himself 
reproduced the accident, by straightening the arm, through the action of 
the biceps upon the upper end of the radius. The father declined any 
further surgical interference, and no prosecution has followed. 

The late Dr. Batchelder, of New York, in a very excellent paper on 
dislocations of the head of* the radius, has described a method of reduc- 
tion suggested to him first by Dr. Goodhue, of Chester, Vermont, and 
which he had himself found more successful than any other method; 
indeed, li<- says it never fails, yet he does not inform us in precisely how 
many cases he had made the trial. The plan suggested by Dr. Good- 
hue consists essentially in first making extension from the hand, and 
pressing at the same time downwards and backwards upon the head of 
tin- radius until it ha- descended to a level with the articulating surface 



DISLOCATIONS OF HEAD OF RADIUS BACKWARDS. 749 

of the humerus. As soon as this is accomplished, the forearm is to be 
suddenly flexed upon the arm in such a direction as that the hand shall 
pass outside of the shoulder ; at the same moment, also, the pressure 
must be continued vigorously upon the head of the radius. 1 

\ 2. Dislocations of the Head of the Radius Backwards. 

Denuce has collected fourteen examples of this dislocation ; but MaJ- 
gaigne, who rejects a portion of the cases, and adds one or two more, 
admits only twelve. In addition to those mentioned by these two 
writers. I have found recorded, or incidentally noticed, one by May, 2 
one by Bransby Cooper, 3 one by Lawrence, 4 one by Liston, 5 two by 
Case. 6 two by Gibson, 7 one by Parker, 8 three by Markoe, 9 two by 
Conner, 10 one by Mack, 11 and one by Rivington, 12 and to these my own 
observations have added five more, in all thirty-three supposed examples. 

Of the examples brought under my own notice I have already, in the 
preceding section, affirmed that two of them were accompanied with 
fracture, and I am not entirely certain but that all except one were. 
Markoe, of New York, whom I have mentioned as having reported 
three cases, found in each case a fracture of the internal condyle of the 
humerus, and. after an examination of a number of the reported ex- 
amples, he does not find any evidence that this dislocation ever occurs 
as a simple uncomplicated accident. It seems quite certain, however, 
that the backward dislocation does so occur, yet it is no doubt exceed- 
ingly rare ; but the following case, brought to my notice by Dr. John 
James Berry, of Fall River, Massachusetts, must be accepted as a 
genuine example, inasmuch as the mode of its occurrence seems to pre- 
clude a fracture: "Frederick Kuger, of New York, was seen by me 
December T, 1879, when he was fifteen years old, having a dislocation 
of the head of the left radius backwards, which the mother stated was 
caused by a convulsion when he was one year old. The button-like head 
of the radius could be distinctly felt, and there was no evidence of any 
other injury." 13 

The example reported by Parker as having happened in the practice 
of X. K. Freeman, of this city, is one of the few also which seems to 
admit of but very little doubt. 

In July, 1850. Dr. Freeman was called to see a gentleman, aat. 37, 
who was seriously injured by jumping from the railroad cars while they 
were in motion, and found a backward dislocation of the head of the 

I Goodhue, New York Journ. of Med., May, 18-36, p. 333. 

- May, Sir Astley Cooper on Dislocations, etc., by J>. Cooper, op. cit. , p. 403. 
3 B. Cooper, Ibid., p. 404. * Lawrence, Pirrie's System of Surgery, p. 259. 

5 Liston. Practical Surgery, p. 88 

8 Case, Amer. Journ. of .Sled. .Sci., vol. vi. p. 204, from 11th No. of Provincial 
tte. 
Gibson, Institutes and Practice of Surgery, 6th ed., vol. i. p. 379. 
8 Parker, New York Journ. of Med., March, 1852, p. 188. 

>:oe, Ibid., May, 1855, i 
« P. S. Conner. The Clinic, Aug. 16, 1874. 

II G. J. Mack. The Med. Record, Dec. 2, 1876, p. 77'.'. 
12 Rivington, Lend. Hosp., Lancet, Dec. 27, 1879. 

11 Berry. N. V. M LG ' vol. vii. No. 6, Feb. 7, U 



750 DISLOCATIONS OF THE HEAD OF THE RADIUS. 

radius of the right arm. "The symptoms," says Dr. Freeman, "were 
marked : the hand and forearm were prone, and the attempt to place 
them in the supine position caused great pain; while the head of the 
radius formed a considerable projection posterior to the external condyle 
«>f the humerus, where the cavity on its extremity could be distinctly 
toll. Assisted by Dr. Walsh, of Fordham, who firmly grasped the hume- 
rus, 1 was enabled to reduce it by extending the forearm and flexing it 
upon the arm, at the same time pronating the hand, and pressing for- 
wards the head of the radius with my thumb. After the reduction was 
effected, I requested Dr. Walsh to examine it ; when upon slight exten- 
sion being made upon the forearm, with supination of the hand, the bone 
was again dislocated. I immediately reduced it in the same manner as 
before, and directed the patient to keep the forearm flexed and the hand 
prone, and, laying it upon a pillow, apply cold water. He complained 
of severe pain for two days, which gradually subsided, and on the fourth 
day he was able to move and extend the forearm." 

The case reported to me originally by Dr. Mack, of Waterloo, Iowa, 
and already referred to as published in the Record, appears to have been 
clearly made out. 

Causes. — The usual causes are, a direct blow upon the front and upper 
part of the radius ; a fall upon the elbow, or upon the hand; a violent 
effort to supinate the forearm while it is grasped and held firmly in a 
state of pronation; and probably it is sometimes occasioned by a twisting 
of the arm in machinery, etc. 

Pathological Anatomy. — In the case reported by Sir Astley Cooper, 
in which a dissection was made, "the coronary ligament was found to be 
torn through at its forepart, and the oblique had given way. The cap- 
sular ligament was partially torn, and the head would have receded much 
more, had it not been supported by the iascia which extends over the 
muscles of the forearm." The head of the radius was thrown behind 
the external condyle of the humerus, and rather to the outer side. This 
was an ancient dislocation found in the dissecting-room of St. Thomas's 
Hospital, and the accompanying drawing is copied from the sketch made 
at the time. 

Two specimens have been presented to the Anatomical Society of 
Paris of* complete ancient dislocation backwards, one by Guion 1 and one 
by Petit.- In Guion's specimen the man w r as at the time of his death 
about fifty years old, and the ligamentous apparatus of the joint seemed 
to ho uiitoin ; ;i fact which might easily be explained by supposing that 
in the great lapse of time since the accident it may have been recon- 
structed. The same was the fact in Petit's case, and probably admits of 
the same explanation. The accident had happened in childhood, and death 
occurred when the patient was twenty-eight years old. Osteophytes existed 
to ;t considerable extent, and the trochlear surface of the humerus was 
notably deformed. 

If the dislocation is not complete, as I have before stated occasion- 
ally happens with children, the annular ligament may not be torn. In 

1 Guion, Bull. Soc. Anat. de Paris, 1859, p. 350. 

2 Petit, Ibid., 1874, p. 004. 



DISLOCATIONS OF HEAD OF RADIUS OUTWARDS. 



751 



Fig. 295. 



such examples the projection of the head of the radius may not be easily 
recognized, but the motions of flexion and rotation would be impaired. 
The reduction is sometimes effected spontaneously, or with slight manipu- 
lation. In some cases, however, the reduction is difficult or impossible, 
owing perhaps to the slipping of the annular ligament over the head of 
the bone, or to some other interarticular complication. 

Poinsot, in a note to the French edition of this treatise, has seen fit to 
recognize these partial dislocations forwards or backwards, when occa- 
sioned in childhood by lifting the body by the arms, as a distinct variety 
of radial dislocations, or, as he has designated them, " dislocations of the 
head of the radius downwards (by elongation)". The grounds upon which 
he bases these distinctions are ingenious and specious, but they do not 
seem to me satisfactory. 

Symptoms. — The head of the bone is felt rotating behind the outer 
condyle, and a depression exists corresponding to its original position. 
The forearm is slightly flexed and prone ; and the 
whole arm is deflected outwards from the elbow 
downwards ; flexion and extension are difficult, while 
supination is impossible. 

Treatment. — Most surgeons have taught that while 
extension and counter-extension are being made, the 
forearm should be forcibly supinated, and that at the 
same time the head of the* radius must be strongly 
pushed forwards. Martin recommends to extend 
forcibly, and then suddenly flex the arm ; in a man- 
ner very similar to the plan recommended by Batch- 
elder in dislocations forwards. In Dr. Freeman's case, 
just quoted, the reduction was effected while the fore- 
arm was pronated, and supination seemed to throw it 
again out of place. Dr. Middleditch, in the case re- 
ported by Mack, succeeded in his first effort, by 
making extension, with the arm flexed to a right 
angle, while pressure was made upon the head of the 
radius. 

According to Markoe, where the accident is compli- 
cated with a fracture of the inner condyle, when the 
reduction is accomplished the arm should be placed in 
a position about ten degrees less than a right angle, 
and supported by a splint with bandages, etc. 

If the dislocation is simple, however, I can see no objection to its 
being nearly or <juite extended, since in this dislocation the action of the 
biceps would only tend to retain the head of the radius in place. 




Dislocation of the 
head of the radius 
backwards. 



I 3. Dislocations of the Head of the Radius Outwards. 

Denuce has collected four examples of this accident, unaccompanied 
with a fracture, and he proceeds to speak of it as a distinct form of dis- 
location. In two of the examples, however, mentioned by him, it was 
consecutive upon a forward dislocation, and I have several times seen the 
head of the radius very much inclined outwards in what are properly 



752 DISLOCATIONS OF THE UPPER END OF THE ULNA. 

termed forward dislocations. For these reasons it is not very plain to 
me thai we ought to consider this as a distinct form of primary disloca- 
tion : bui it would seem that we ought rather to regard it as a consecutive 

dislocation, or at least as only a modification of the forward or backward 
dislocation. Indeed. 1 think the radius never will be found thrown directly 
outwards, but always in a direction inclining forwards or backw r ards. 

Parker, of this city, mentions a ease which came under his notice, in 
a child lour years old, who, six weeks before, had fallen down stairs 
"backwardly, with the right arm twisted behind the back, in such a 
position that the whole weight of her body came upon her arm." No 
attempt was ever made to reduce the bone, and the head of the radius 
continued to project externally. By pressure it was easily reduced, but 
became immediately displaced when the forearm w T as either flexed or ex- 
tended. The motions of the joint were completely restored. Dr. Parker 
recommended no treatment. 1 



CHAPTER IX. 

DISLOCATIONS OF THE UPPER END OF THE ULNA 
(HUMERO-ULNAR). 

I 1. Dislocations Backwards. 

This accident, the existence of which, as a simple dislocation, is placed 
beyond doubt, has nevertheless been described so variously, and often 
indefinitely, that it is impossible to declare its history, except in a few 
points, with any degree of accuracy. No doubt many of the cases which 
have been reported w r ere examples only of a subluxation of both radius 
and ulna backwards. In other cases, the radius or the external condyle 
of the humerus being broken, the ulna has been actually displaced, not 
only backwards, but upwards; indeed, it is very certain that wdthout 
either dislocation of the radius, or a fracture w T ith displacement of the 
externa] condyle of the humerus, or a fracture or bending of the radius, 
an upward displacement of the ulna, to the degree represented by the 
reporters of these cases, could never have occurred. The example men- 
tioned by Sir Astley Cooper, and of which a dissection was made, is 
plainly ;i case of subluxation of both bones; or if the dislocation of 
the ulna may be regarded as having been complete, the head of the radius 
was also displaced more or Less upwards from its original socket; a new 
socket, Sir Astley himself informs us, having been formed for its recep- 
tion, upon the external condyle. But this is the only example, the actual 
condition of which has been proven by an autopsy. 

Nevertheless, it seems certain that a simple dislocation or subluxa- 
tion of the ulna backwards may occur without either of the above-men- 
tioned complications, and that, to the extent of a few lines, it maybe 

1 Parker, New York Journ. Med.. March, 1852, p. 189. 



DISLOCATIONS OF ULNA INWARDS. 753 

made to pass upwards upon the back of the humerus, by the falling of 
the forearm to the ulnar side ; in which case the character of the accident 
would probably be recognized by the projection of the olecranon process, 
while the head of the radius might be felt moving in its socket ; by the 
partial flexion and complete pronation of the forearm, and by the gen- 
eral immobility of the joint. In a case reported by Dr. Waterman, 
caused by a fall on the hand, the arm was at a right angle, and pro- 
nated. 1 

Its reduction ought to be accomplished easily, one would think, by the 
same measures which have been found successful in reducing a disloca- 
tion of both bones backwards; but in Waterman's case this method 
failed, and the reduction was promptly effected by bending the forearm 
forcibly back. 

Pirrie says that in a case occurring in the practice of Mr. Gosset, in 
which the coronoid process rested on the internal condyle, and the pain 

Fig. 296. 




Dislocation of the upper end of the ulna backwards. 

on bending the arm was insupportable, owing, it was supposed to the 
pressure of the coronoid process against the ulnar nerve, "reduction 
was accomplished by extension and counter-extension applied by two 
persons pulling in opposite directions, and by the pressure of the ole- 
cranon process downwards and outwards, while the forearm was sud- 
denly flexed." 2 

JRosner 3 employed with success the same procedure in a case of incom- 
plete dislocation, which had existed eight months in a boy, set. 18. 

§ 2. Dislocations Inwards. 

In 1882, Dr. George Wright, of Toronto, 4 reported an example in a 
girl nine years old, of dislocation inwards of the upper extremity of the 
ulna, the head of the radius remaining in place, caused, as was supposed, 
by a fall upon the elbow. Dr. Wright saw the patient the same day 
and recognized the dislocation, but as some of the surgeons who saw the 
expressed a doubt as to the character of the accident, no attempt 
at reduction was made. Twenty-eight days after the accident, "A care- 
ful examination was made by almost all the members of the staff, and 

1 Waterman, Boston Med. and Surg. Journ., vol. iv., new series. 
:. Pirrie'a Surg., A him-, ed., p. 259. 

3 Rosner, Wiener Allgem. Med. Zeitung, 1875, No. 32. 

4 Wright, Canadian Journ. Med. Sci., Feb. 1882. 

48 



754 DISLOCATIONS OF THE RADIUS AND ULNA. 

accurate measurements between the bony prominences were taken, and 
all agreed that there was dislocation inwards of the olecranon process 
upon the inner condyle of the humerus, the head of the radius remain- 
ing in its normal position. There was no pain or swelling; all the 
motions of the arm were perfect ; but the patient was unable to sustain 
any weight upon the arm in extension by reason of the tendency to 
rotate inwards, and the "carrying power" was lost. I attempted reduc- 
tion under anaesthetics, but after an hour and a half's effort by myself 
and all the gentlemen present, and by every means suggested by the 
best authorities, we failed to reduce the dislocation. The arm was put 
in an elevated easy position, with patient in bed, cold water applied, and 
not a single bad symptom followed this somewhat violent manipulation. 
The friends refused to allow any further attempts at reduction." 

In explanation of the peculiarity of the displacement, Dr. Wright 
states that there existed a congenital laxity of the ligaments of all the 
joints, and that "when the child w T as two years of age she received an 
injury to this same elbow which caused the separation of this epiphysis, 
the external condyle being broken off, and it may be that this accident 
left a condition in the joint which favored the possibility of the inward 
displacement of the upper extremity of the ulna without carrying the 
radius with it." 



CHAPTER X. 

DISLOCATIONS OF THE KADIUS AND ULNA (FOREAKM) AT THE 
ELBOW-JOINT. 

Thi: radius and ulna may be dislocated at the elbow-joint backwards; 
laterally, that is, either inwards or outwards; and forwards. They may 
also be dislocated in opposite directions. 

§ 1. Dislocations of the Radius and Ulna Backwards. 

Causes. — My records of private and hospital practice supply seventy- 
two cases; the youngest being four years old, and the oldest sixty-one. 
Twenty-nine of this number occurred in children under fourteen years 
of age. 

Generally the dislocation has been produced by a fall upon the palm 
of the hand, as when in running a person has fallen forwards with the 
forearm extended in front of the body, or he may have fallen from a 
height; once I have known it produced by a blow received upon the back 
and Lower pari of the humerus; and in several instances the patients 
have declared thai they had fallen upon the elbow; it is produced, occa- 
sionally, by twisting the forearm violently, as when the limb has been 
caught and wrenched about by machinery, by a blow upon the front and 
upper part of the forearm, and by forced flexion. 



DISLOCATIONS OF RADIUS AXD ULNA BACKWARDS. 755 



Fig. 297. 




Dislocation of the radius and 
ulna backwards. 



Pathological Anatomy. — The radius and ulna are not onlv carried 
backwards behind the articulating surface of the humerus, but "they are 
also, through the action of the triceps, almost 
always drawn more or less upwards, so that 
often the coronoid process of the ulna rests 
in the olecranon fossa. In some cases it has 
been known to mount even higher, while in 
others it is arrested short of this point. The 
radius still retaining its relative position to 
the ulna, lies upon the back of the humerus, 
or rather upon the posterior margin of its 
articulating surface. 

The anterior and two lateral ligaments are 
generally more or less completely torn asun- 
der ; but the posterior ligament and the annu- 
lar do not usually suffer disruption. 

The biceps muscle is drawn over the lower 
articulating surface of the humerus, but is in 
a condition of only moderate tension, w^hile 
the brachialis anticus is forcibly stretched, 

or even torn. Malgaigne says the tendon of the biceps has once been 
found behind the humerus. 

The median nerve is also pressed upon in front by the humerus, and 
the ulnar is occasionally painfully stretched over the projecting extremity 
of the ulna from behind. 

Symptoms. — Sir Astley Cooper does not mention particularly the 
position of the arm as to flexion or extension, except to say that "the 
flexion of the joint is in a great degree lost; " nor, in his original work, 
published in London in 1823, is there any illustration accompanying 
the text to indicate in what position he had usually seen the limb ; but 
in the later editions, edited by Mr. Bransby Cooper, is found a drawing 
which represents the forearm at a right angle with the arm. It is very 
certain that Sir Astley never sanctioned this error by anything which 
he had written or communicated to others. It is very certain, I say, 
because the fact that it seldom, if ever, occupies, this position, could 
not have escaped the notice of one whose experience was so large, and 
whose habits of observation were generally so accurate. The truth is 
that it is almost constantly found only slightly flexed, or forming an 
angle in front of about 120°. 

This fact is especially noticed in my records twenty-six times, and, 
if it had ever been found in any other position, it would certainly have 
been Btated. ( Mire, where the dislocation was accompanied with a 
fracture of the outer condyle of the humerus, the arm was at first 
straight, a position in which it is said to be found occasionally with 
children; and in the case of a patient admitted to Bellevue Hospital, 
on the 14th of December, 1- s <;4. the dislocation having existed thirty- 
one days, but unaccompanied with a fracture, I found the arm straight, 
and there existed also a preternatural lateral mobility of the elbow- 
joint : but never, in any ease of a recent dislocation, and but once in 
an old dislocation, have I found it flexed to a right angle ; yet I will 



756 hlSLOCATIONS OF THE RADIUS AND ULNA. 

not deny that such unusual phenomena are possible in recent disloca- 
tions: indeed, it is certain that they have occasionally been presented, 
hut they must be regarded as only exceptional, and as by no means 
diagnostic of this accident. 

Sir Astley Cooper and Miller declare that in this dislocation the fore- 
arm is usually supinated; Pirrie says "the hand is between pronation 
and supination, but more inclined to the latter." Desault thinks it is 
sometimes in supination and sometimes in pronation; Denuce concludes 
that it will occupy that position, whatever it may be, in which the force 
of the blow has thrown it; while by most surgical writers no allusion is 
made to the position of the forearm in reference to pronation or supina- 
tion. For myself, I can only say that I have found the forearm and hand 
almost constantly in a position of moderate but positive pronation, and I 
am compelled to regard it, therefore, as one of the usual signs of a back- 
ward dislocation of these bones. 

The limb can be neither flexed nor extended without force, and such 
motion is almost always accompanied with pain. It is, however, possible 
in most cases to give to the arm a slight lateral motion, such as does not 
belong to it in its natural condition. 

In front, and deep in the fold of the elbow, is felt the lower end of 
the humerus, forming a hard, broad, and somewhat irregular projection, 
over which the integuments and muscles are swollen, and tender to 
pressure. Behind, the head of the radius may be felt, when not much 
tumefaction exists, rotating or moving under the finger when the fore- 
arm is supinated and pronated ; while the olecranon process projects 
strongly backwards and upwards. If now we flex the arm slightly, 
this projection of the olecranon process will be sensibly increased; but 
if an attempt is made to straighten the arm, it will be diminished, the 
reverse of what we have seen to happen in cases of fracture of the lower 
cud of the humerus (at the base of the condyles). This circumstance 
becomes, therefore, an important diagnostic mark between these two 
accidents. 

The relation of the olecranon process, also, to the condyle is changed, 
and the upper end of this process, instead of being a little below the in- 
ternal condyle, as it would be naturally when the arm is slightly flexed, 
is found generally carried upwards toward the shoulder, from half an 
inch to one inch or more above the condyle. 

Measuring from the internal condyle to the styloid process of the 
ulna, the forearm is shortened; the same result will be obtained also by 
measuring from the acromion process to either of the styloid processes ; 
while from the acromion process to the condyle, the length will be the 
same in both arms. 

The signs which have now been enumerated will be sufficient to 
enable us to make the diagnosis promptly in the great majority of 
8, but, if considerable swelling has already taken place, the diag- 
nosifl may he rendered exceedingly difficult, if not impossible; and in 
Buch cases we should confine the patient at once to his bed, and proceed 
to reduce the tumefaction by appropriate means as rapidly as possible, 
examining the limb carefully from day to day, in order that we may 



DISLOCATIONS OF RADIUS AND ULNA BACKWARDS. YD i 

seize the earliest opportunity to ascertain its actual condition and to 
effect the reduction. 

In relation to the difficulty of diagnosis in certain examples of this 
accident, and under certain circumstances, Mr. Skey, in his Operative 
Surgery, has made some very judicious remarks : 

"Severe injuries of the elbow-joint, whether in the form of fracture, 
dislocation, or a compound of the two, are frequently followed, at a 
short interval, by swelling of a formidable kind, in which it is impos- 
sible, but by the aid of a perfect intimacy with the anatomical structure 
of the joint, to detect the relations of one part with another; but even 
under this difficulty, the two points in question are readily distinguish- 
able. In such forms of swelling, the arm, including the length of six 
inches both above and below the joint, may be involved in the extrava- 
sation, and this swelling may distend the arm to a circumference of one- 
third beyond its natural size. In such circumstances, in which it is 
impossible to determine with any certainty whether any, or what bones 
are broken, or whether or not dislocated, the difficulty of the case should 
at once be stated to the friends of the patient." 

Prognosis — If the dislocation is recent, reduction is in general easily 
effected ; but if considerable time has elapsed, the reduction is often 
accomplished with difficulty. As to the probability of its redislocation, I 
have already spoken when considering the subject of fractures of the 
coronoid process. Unless this process is broken, it is not likely to occur 
except where some violence has again been applied. It has happened 
to me, however, to find these bones unreduced in several instances. In 
some of these examples surgeons recognized the accident and supposed 
that they had accomplished reduction, while in others the disclocation was 
mistaken for a fracture. 

A lad, AY. F., twelve years old, residing in Erie County, N. Y., was 
brought to me six weeks after the accident had occurred. The surgeon 
who was first called declared it to be a dislocation, and told the parents 
he had reduced it : but the dislocation was now complete, and the arm 
immovably fixed in its abnormal position. 

On the"lOth of May, 1850, J. P., of Canada West, ret. 25, was thrown 
from a load of hay, striking upon his left hand, and producing a disloca- 
tion backwards of both bones at the elbow-joint. A Canadian surgeon, 
who saw the patient within three hours, recognized the dislocation, and by 
pulling the arm straight forwards he supposed he had reduced it ; the 
patient also thought he felt the bones slip into place. No attempt was 
made subsequently to flex the arm, and it was immediately dressed with 
a straight splint laid along the palmar surface. On the sixth day it was 
found to be unreduced, and the surgeon again attempted to reduce it as 
before, and thought he had succeeded. The same splint was reapplied. 
At about the end of six weeks three surgeons, residing in Canada also, 
placed the patient under the complete influence of chloroform, and 
attempted the reduction. They first made extension for half an hour in 
a straight line, then five men seized upon the arm and forearm, bending 
it with great force to a right angle. *It was now believed that the ulna 
was reduced, but not the radius. Four days after, the attempt was 
renewed. Three months after the accident the young man called upon 



758 DISLOCATIONS OF THE RADIUS AND ULNA. 

me, and I found the arm Dearly straight, with almost complete anchylo- 
sis ar the elhow-joint. Both the radius and ulna were displaced back- 
wards, but not upwards. The arm was of the same length with the 
other, and the relation of the condyles to the olecranon was so manifest, 
that the absence of the usual displacement upwards was easily deter- 
mined. 1 was unwilling to make any further attempts at reduction, not 
believing that I should succeed after so much time had elapsed, and after 
BO many ineffectual attempts had been made by clever surgeons. 

In the following examples the dislocation was supposed to have been 
a fracture of the lower end of the humerus. 

A man, residing in Pittsfield, Mass., dislocated his left arm by falling 
from a horse. The surgeon who was called regarded it as a fracture at 
the base of the condyles, and treated it accordingly. Ten weeks after, 
the error was discovered and an attempt was made to reduce it, but 
without success. A second attempt was also made, with the same 
result. 

The patient was brought to me eight months after the accident, with 
the bones still unreduced. The forearm hung at a very obtuse angle 
with the arm, and there was very slight motion at the elbow-joint. I 
discouraged any further attempts at reduction. 

Mr. W., of Alleghany Co., N. Y., set. 43, fell from a load of hay, 
striking upon his left arm, Feb. 16, 1853. Four hours after, he was 
seen by a young but very intelligent surgeon, who thought the humerus 
was broken just above the condyles. After eight weeks, the fact that it 
was a dislocation having become apparent, three surgeons, well known to 
me as men of large experience, attempted its reduction aided by pulleys 
and chloroform. The patient was also bled, and nauseated with anti- 
mony. The efforts were protracted through many hours, and frequently 
varied. A second attempt made by these same gentlemen, a few days 
after, was equally unsuccessful. 

On the ninth week Mr. W. came to me, and I placed him at once in 
the Buffalo Hospital of the Sisters of Charity, where, assisted by my 
friend Prof. Moore, of Rochester, I renewed the attempt at reduction. 
The patient was placed under the influence of chloroform, and during a 
great portion of the time occupied the pulleys were in use. The elbow 
was ] »ullcd upon, twisted, flexed, and extended, until there seemed to be 
neither adhesions, nor ligaments, nor capsule, to prevent the reduction. 
We could move the joint in every direction, even laterally, as well as for- 
wards and backwards. Still the bones would not return to their sockets. 
Section of the triceps seemed to be the only remaining expedient, but 
tlie injury already done to the joint was so great that we did not deem 
it prudent to prosecute the attempt any further. We had occupied two 
hours in the various procedures. Violent inflammation supervened, but 
he was able to return home in about two weeks. Two years after, I 
learned that the arm still remained unreduced, and nearly anchylosed ; 
the whole limb was also much atrophied and very weak. 

John Sharkie, set. 53, fell on the 4th of August, 1854. A botanic 
doctor, who saw liini on the same day, and a regular physician, who saw 
him on the third day. thought he had broken his arm. About six weeks 
after this he came under the charge of an almshouse doctor, who "re- 



DISLOCATIONS OF RADIUS AND ULNA BACKWARDS. 759 



Fig. 298. 



broke "' it, supposing it to be a fracture ; and two months later he "broke " 
it again : but as the arm was not improved by these operations, he finally 
urged upon the poor fellow to submit to amputation ; and it was in refer- 
ence to this last proposition that Sharkie consulted me. I found the 
radius and ulna dislocated backwards and upwards one inch ; the arm 
perfectly straight and the elbow anchylosed ; no pronation or supination. 
I did not think it prudent to make any attempt to reduce it, but assured 
him that if let alone it would ultimately be quite useful in many ways, 
and that he should never think of having it cut off. 

In at least eleven additional cases, according to my records, the acci- 
dent has been overlooked by reputable surgeons ; the injury having been 
supposed to be either fracture or a 
mere contusion. Two of these had 
been examined by house surgeons at 
Bellevue. In one other case my house 
surgeon supposed he had reduced the 
dislocation, when he had not. 

In three or four instances, also, the 
accident has been overlooked by the 
patient himself, or by some empiric, 
no surgeon having been called to see 
the case until after the lapse of several 
days or weeks. 

In general, when the reduction has 
been effected promptly, the patients 
have recovered the complete use of the 
elbow-joint within a few weeks; but 
many exceptions have from time to 
time come under my notice. 

A lad eight years old was brought 
to me, whose arm had been dislocated 
six months before, and the reduction 
of which had been accomplished easily 
and promptly by Sir Astley Cooper's 
method. At this time the arm was 
bent to a right angle, and quite stiff 
at the elbow-joint. Four years later 
I learned that the stiffness still continued in a great measure, with only 
si ight i m pro v< ment. 

Treatment. — Sir Astley Cooper thus describes his own method of re- 
ducing this dislocation: " The patient is made to sit upon a chair, and 
the surgeon, placing his knee on the inner side of the elbow-joint, in the 
bend of the arm. takes hold of the patient's wrist, and bends the arm. 
At the same time he presses on the radius and ulna with his knee, so as 
to separate them from the os humeri, and thus the coronoid process is 
thrown from the posterior fossa of the humerus; and while this pressure 
is supported by the knee, the arm is to be forcibly but slowly bent, and 
the reduction is soon effected." 

The same practice has been recommended by Erichsen, Gibson, Samuel 
Cooper, and others. The plan recommended by Dorsey is nearly iden- 




Reduction with the knee in the bend of 
the elbow. 



760 DISLOCATIONS OF THE RADIUS AND ULNA. 

tioal with that just described, only that, instead of the knee, he advises 
that the surgeon "interlock his fingers in front of the arm, just above 
the elbow, and draw it backwards." 

On the other hand, Liston and Miller recommend, as a better mode of 
procedure, that the patient shall be seated upon a chair, and that the 
arm and forearm shall be pulled directly backwards, so as to relax as 
completely as possibly the triceps muscle, while counter-extension is 
made against the scapula. 

Skey says: "Extension of the forearm should be made from the hand 
or wrist in a straight direction downwards, as if for the purpose of simply 
elongating the arm." 

Pirrie prefers that an assistant shall grasp the forearm near its middle, 
instead of the wrist, and pull the arm straight forwards, while at the 
same moment the surgeon seizes upon the olecranon process with the 
fingers of one hand, and, placing the palm of the other against the front 
and upper part of the forearm, pulls forcibly backwards, so as to draw 
out the coronoid process from the olecranon fossa. Waterman recom- 
mends forced extension; that is, bending the forearm forcibly back, as 
preliminary to flexion, with the view of lifting the coronoid process from 
the olecranon fossa. 1 

For myself, having generally practised the method recommended by 
Sir Astley, and having usually succeeded in the first attempt and with 
the employment of only moderate force, I confess that my predilections 
are in its favor; yet I am not entirely certain but that an equal experi- 
ence with either of the other modes recommended might have changed 
those convictions. The truth is, I think, that in recent cases very little 
force is generally requisite to accomplish the reduction, and that it is 
not very material which of these several modes we adopt; but in case 
of a failure by one mode, we ought immediately and without hesitation 
to resort to another, as the following case of a failure by flexion will 
illustrate : 

A lad, aet. 11, fell in a gymnasium from a height of six feet, striking 
probably upon his hand. I saw him within twenty minutes, and found 
tin- ;nni in the usual position. I attempted immediately to reduce it by 
Sir Astley s method, but after a fair yet unsuccessful trial, I extended 
the forearm upon the arm until it was nearly straight, and then, with 
only moderate force, drew it promptly into place. 

If we still continue to encounter difficulties, the patient ought at once 
to be placed under the influence of an anaesthetic, and, if necessary, the 
pullevs should be employed. 

When the reduction is accomplished, which is indicated generally by 
the sudden slipping of* the hones and by the restoration of the natural 
form to the elbow-joint, the surgeon, in order to confirm his opinion, 
must flex the forearm upon the arm to a right angle. If the bones are 
in place, and there is not much swelling, this can generally be done 
without causing much, if any. pain; but if it cannot be done, this fact 
furnishes presumptive evidence that the reduction is not effected. In 

1 New Method of Reduction of the Elbow, by Thomas Waterman, M.D., Boston 
Bfed. and Surg. Journ., v..]. frr. Nos. 12, 13, new series, 1869. 



DISLOCATIONS OF RADIUS AND ULNA BACKWARDS. 761 

one instance, however, of recent dislocation, this rule has not held good. 
A girl, let. 10, fell from a tree upon her hand. I was in attendance 
within half an hour, and found the usual signs characterizing this acci- 
dent. Reduction was accomplished readily by pulling at the hand mode- 
rately, with the forearm flexed, while my left hand pressed back the 
lower part of the humerus. After the reduction it was found impossible 
to flex the arm to a right angle without causing severe pain, and it 
became necessary, after placing it in a sling, to allow the hand to drop 
very low beside the body. A good deal of inflammation followed ; but 
in a few weeks the arm was well, only that for a period of two years or 
more the elbow remained very tender. 

On the other hand, an omission to apply this rule has often led the 
surgeon to believe the reduction accomplished when it was not. This 
same thing has happened to myself, and as it is the only instance in 
which I have omitted to adopt this test, and the only one also in which 
I have left a bone unreduced which I believed to have been reduced, it 
will be proper to state the case and its results more fully. 

A lad. a?t. 11, fell from a fence on the 22d of December, 1858, and 
dislocated both bones backwards. I saw him within two hours from the 
occurrence of the accident. The elbow was already considerably swollen 
and quite tender, but the signs of dislocation were very manifest. Seizing 
the wrist with one hand, and placing my knee against the front and lower 
part of the humerus, I pulled steadily for some time, and with much 
more force than is usually necessary, until at length two distinct and 
successive snaps were felt, such as one often feels when the two bones 
resume their sockets. Relinquishing my grasp, it was observed by 
myself and the parents that the deformity had disappeared. The reduc- 
tion seemed to be complete, and so I announced. I then requested the 
lad to permit me to bend the elbow, and place it in a sling, but this he 
peremptorily refused to do, and ran away from me, nor would any argu- 
ments or entreaties persuade him to allow me again to touch it. I re- 
assured the parents and child, however, that all was right, and left the 
house. During several successive days I saw the little patient, but 
although the arm remained swollen and very tender, I did not suspect 
the cause until the ninth day ; and on the tenth day, having placed him 
under the influence of chloroform, the reduction was easily and satisfac- 
torily accomplished. The recovery was slow. At the end of six weeks 
I found the motions of the elbow joint not completely restored, and the 
forefinger was partially paralyzed; but from this condition it gradually 
recovered, and two months later the functions of the arm and hand were 
completely restored. 

The mistake in this instance was the more mortifying because I had 
just seen a case in a lad only a little older, in which another surgeon 
had committed the same error, and after the lapse of twelve or fourteen 
day- I bad myself made the reduction; and I was fully awake, therefore, 
to the possibility of the mistake. 

The circumstance of the diminution and apparent disappearance of 
the deformity, and the sensation of a double click, can only be explained 
by assuming that originally the coronoid process was resting in the 
olecranon fossa, and that by manipulation the bone- had been removed 



762 DISLOCATIONS OF THE RADIUS AN J) ULNA. 

Dearer their sockets, yet not actually reduced. The swelling, also, 
rendered more difficult a diagnosis which, now, nothing but the flexion 
of the forearm could have determined positively. 

If much time has elapsed since the occurrence of the dislocation, the 
reduction is accomplished with difficulty, if, indeed, it can be reduced at 
all. Their are many cases upon record, however, in which surgeons 
have been successful after the lapse of many weeks, or even months. 
Boyer thought it was not possible to effect the reduction after four or 
six weeks ; hut Cappelletti, of Trieste, succeeded after seventy days ;* 
Sir Astley Cooper, at three months ; 2 Malgaigne, after three months and 
twenty-one days. 3 Roux succeeded in a case of a young man twenty- 
two years of age, whose elbow had been dislocated five months. 4 Black- 
man, of Cincinnati, informs me that he has reduced a lateral dislocation 
after five months. Brainard, of Chicago, reduced a dislocated elbow in 
a boy of nineteen years, after five months and thirteen days. In this 
case the surgeon who had first seen the patient supposed that he had 
reduced the dislocation. 5 Gorre, Gerdy, and Drake succeeded in four 
cases after six months; 6 I have succeeded at seven months; and Starch 
claims to have been successful after two years and one month. 7 To 
which enumeration Denuce has added seventeen other examples said to 
have been reduced at various periods ranging from one month to one 
hundred and fourteen days. 8 

I have reduced a number of these old dislocations, the last five of 
which will be briefly recorded. 

Thomas Robertson, aet. 35, was admitted to Bellevue Hospital, De- 
cember 14, 1864, with a simple dislocation of the radius and ulna back- 
wards, which had existed thirty-one days, but which had not been up to 
this moment recognized by his surgeon. I reduced it before the class, 
by Sir Astley 's method, the patient being under the influence of ether. 
Considerable force was required. 

J. G., aet. 7, was brought to me in November, 1865, with a backward 
dislocation of the right radius and ulna, which had existed nine weeks. 
The arm was nearly straight and fixed. Having placed him under the 
influence of ether, assisted by Dr. Gurdon Buck, of this city, I pro- 
ceeded to flex the arm slowly, and after a few seconds, and when the 
elbow was bent about ten or fifteen degrees, the olecranon process sepa- 
rated at the line of epiphyseal union. In a few moments the reduction 
was completed, and the arm brought to an acute angle, but the olecranon 
had separated fully half an inch. We were quite certain that the ulna 
was perfectly reduced, but the head of the radius did not seem to occupy 
its original position fully. Only moderate inflammation ensued. Passive 
motion was soon commenced, and considerable motion of the joint was 
finally obtained. 

1 Cappelletti, Am. Journ. Med. Sci., vol. xix. from Annal. Univ. de Med. for Oct. 
1885. 

Astley Cooper, On Dislocations and Fractures, Amer. ed., p. 388. 
:; Malgaigne, Amer. Journ. Med. Sci., vol. xxiii. p. 238, from Revue Med., Dec. 1837. 
1 Roux, Amer. .J<>urn. Med. Sci.. vol. xvi. p. 526, from Archives Gen., Dec. 1834. 

Brainard, Illinois and Indiana Med. Journ., 1847. 
' Memoire Bur lee Luxations de Coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 
ice*, op. <"it., p. 87. 8 Op. cit. 



DISLOCATIONS OF RADIUS AND ULNA BACKWARDS. 763 

In April, 1869. a gentleman, ret. 30, consulted me on account of a 
dislocation which had then existed ten weeks, and which had not been 
recognized by his surgeon. In attempting to reduce the dislocation 
I fractured the olecranon, and brought the ulna into position, but I 
could not reduce the radius. Almost complete anchylosis of the elbow 
remains. 

In 1870. a man was brought to me whose elbow had been dislocated 
eight weeks. Under ether, I succeeded in reducing the dislocation, but 
fractured the olecranon process in doing so. He has recovered very 
good use of the joint. 

October 22, 1869, before the class of medical students at Bellevue, I 
reduced a dislocation in the case of a woman aet. 37, which had existed 
since the 10th of the preceding March, a little more than seven months. 
I have seen her often since ; she has a somewhat limited but very useful 
motion of the joint. 

A few years since I assisted Dr. Say re in reducing an old backward 
dislocation of these bones in the case of a boy. Other means having 
failed, while Dr. Sayre forcibly flexed the arm, I cut the triceps, after 
which the reduction was easily effected. Some months later the arm was 
nearly anchylosed at the elbow-joint, and it did not promise very well, 
so far as the usefulness of the member was concerned. 

Dr. W. F. Westmoreland, of Atlanta, Ga., has reported a case in 
which he succeeded readily in reducing a dislocation of the elbow back- 
wards, of five months' standing, in a woman aged 22 years. The reduc- 
tion was followed by great pain, a good deal of swelling, temporary 
impairment of circulation in the radial artery, complete paralysis of the 
little finger, and partial paralysis of the middle and ring fingers. On 
the fourteenth day, at which period the history of the case closes, all 
these symptoms were rapidly disappearing. 1 

Nevertheless, the fact is in the main as stated by Boyer ; and if so 
many cases can be found in which surgeons have succeeded at a late 
period, they are not probably in the proportion of one to five as com- 
pared with the failures. But the failures have not received the same 
publicity. Nor, indeed, have all the severe accidents, such as violent 
inflammation, suppuration, gangrene, and even death, been faithfully de- 
clared. Denuce says he has been able to. trace out five or six examples 
in which, although the arm was reduced, grave accidents resulted, and 
Yelpeau\s patient actually died in consequence. 

Michaux, at the Hopital de Louvain, in 1841, in reducing an elbow 
dislocation, tore off the median nerve and brachial artery. Amputation 
was made and the life of the patient saved. 2 

Dixi Crosby, of New Hampshire, has treated two cases of ancient dis- 
location of the forearm backwards, by bending the elbow forcibly so as 
to break the olecranon process, after which the reduction was easily 
accomplished by extension. R. D. Mussey, of Cincinnati, has succeeded 
once in the same manner. 3 I have reported three similar examples. 
Malgaigne saya that Cappelletti published an example in 1835, and that 

1 "Westmoreland, Atlanta Med. and Surg. Journ., May, 1866. 

2 Debruyn, Des Luxation- du Cotide. These Enaug., Louvain, 1843, p. 77. 

3 Crosl Trans. Amer. Med. Assoc, vol. iii. j». 357. 



764 DISLOCATIONS OF THE RADIUS AND ULNA. 

Morel-Lavallee, Roux, and Maisonneuve had each met with the acci- 
dent. 1 

In 1879, Trendelenburg, 3 in a girl, ret. 15, with an irreducible dis- 
location of eight weeks' standing, having made an external incision, with 
a chisel Beparated the olecranon process from the shaft, and then reduced 
the dislocation. Observing now that, when the arm was flexed there was 
a wide separation of the fragments, he again straightened the arm and 
brought the fragments together with a wire suture. He states that the 
results were satisfactory! 

Voelker, 3 in an old incomplete backward and outward dislocation in 
a boy, set. 13, attended with complete paralysis of the parts supplied by 
the ulnar nerve, severed the olecranon with a saw and then wired the 
fragments together. The result of the operation was a certain degree 
of improvement in the motions of the arm, and the disappearance of the 
paralysis. 

In 1839, Gerdy, 4 in a dislocation of six months' standing, divided 
subcutaneously the triceps and the adjacent adhesions, but he was still 
unable to reduce the dislocation. 

Maisonneuve 5 and Blumhart 6 only effected the reduction after the 
most extensive tegumentary, muscular, and ligamentous dissections. 
Von Wahl, 7 in two cases made an external incision, and having divided 
in one case both of the lateral ligaments, and in the other the external 
only, and having destroyed the adhesions, was unable to effect reduction. 
He proceeded therefore to practise resection of the joint. 

Emmert 8 and Boeckel 9 have each practised resection in similar cases; 
and Oilier 10 has three times resorted to the same expedient in old irre- 
ducible dislocations. 

It is scarcely necessary to say that all of these latter surgical expedi- 
ents should be reserved for exceptional cases. Not one of them is wholly 
free from danger, and the results are not in all cases such as might be 
loped for. Moreover, experience has abundantly shown, and especially 
when the accidents have occurred in early life, that a persistence of the 
dislocation is not incompatible with the subsequent formation of a new 
and very useful joint. 

In a recent case, the dislocation being reduced, it may be a matter of 
prudence, sometimes, to apply a right-angled splint, first carefully 
padded, to the palmar surface of the arm and forearm; remembering, 
however, that considerable -welling will soon occur, and that it ought 
not therefore to be bandaged to the limb very tightly. At least once a 
day it Bhould be removed, and the arm examined; and in a very few 
cases can it be necessary or judicious to continue its application beyond 

1 ftfalgaigne, op. cit., Paris ed., 1855, vol. ii. p. 144. 
■ Trendelenburg, Centralblatt fur Chir., 1880, No. 52, p. 833. 
* Voelker, Deutsche Zeitscbrift fur Chir., Bd. 12, Hft. 6. 
1 Gerdy, Anna], de Chir. Francaise et Etrang., t. 2, p. 151. 

Ifaisonneuve, Poinsot, "p. cit., 918. 
•■ Blumhart, Gaz. MeU de Paris, 1847, p. 238. 
7 Von Wahl,St. Petersburger Med. Wochenschrift, 1879, No. 23. p. 221. 

nert, Rev. M.'<1. Chir., t. 8, p. 177. 
' Boeckel, Frag, de Chir., Paris, 18«2. p. 85. 
in Oilier, Rev. Kens, de Chir., 1882, pp. 722-734. 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 765 

one week. At the same time, if there is any especial tendency in the 
radius to become displaced backwards, owing to a rupture of its annular 
ligament, this must be prevented, if possible, by a compress and bandage. 
Some surgeons regard these precautions as necessary in all cases, but I 
have seldom employed any splint or bandage whatever, nor have I ever 
had reason to regret this omission. 

Finally, we are to place the arm in a sling, and adopt such measures 
as are calculated at first to reduce the inflammation; and at a very early 
day we ought to begin to move the elbow-joint, in order to prevent 
anchylosis. 

Dislocations Backwards and to the Radial Side will be considered 
in connection with outward dislocations; and Dislocations Backwards 
and to the Ulnar Side, in connection with dislocations inwards. 

§ 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side), 
(a) Complete Outward Dislocations. 

The large majority of outward dislocations of the forearm are incom- 
plete; indeed, only nine examples of a complete dislocation have been 
collected by Denuce, including two seen by himself. 1 (In his last 
memoir he has added four more.) Malgaigne has recorded two ; 2 Mol- 
liere, of Lyons, has reported one, 3 Amboni, 4 Hatry, 5 Bertin, 6 have 
each reported one. Andrews 7 has also reported one, and Salleron 
one, 8 Osborne one, 9 Varick one, 10 Wylie one. 11 Dr. Erskine Mason has 
reported two, in children of seven and twelve years respectively, and 
he refers to another reported by one of his colleagues at Belle vue, in the 
Medical Record for Oct. 9, 1875, in the person of a lad aet. 17, 12 making 
in all nineteen cases. Dr. Varick's case is reported as follows : 

" George Knight, set. 9 years, was thrown violently from a wagon while 
in rapid motion, striking on his head and back, with his left arm behind 
him in a state of flexion. He was brought to my office on the 31st of 
August, 1867, within ten minutes after the receipt of the injury, and, 
consequently, in the most favorable condition for manipulation, no swell- 
ing of the soft parts having yet occurred. The forearm was in a state 
of semiflexion, supported by the hand of the opposite side, the ulna lying 
to the outer side of the external condyle, with slight posterior projection 
of the olecranon. The olecranon, coronoid process, and greater sigmoid 
cavity could be distinctly defined, and the head of the radius, in its 
normal relations to the ulna, could be felt rotating subcutaneously on 

; Denucg, Mern. sur. Lux. des Coudes. Paris, 1854. 

Malgaigne, op. cit. 
; Molli&e, Monthly Abstract Med. Sci., vol. i. p. 269, 1874. 

4 Amboni, Annal. Univ. di Med., July, 1872. 

5 Hatry, Lyon M&L, t. 18, p. 13, 1875. 

6 Bertin, Union Med., 1876, p. 609. 

' Andrew.-. Med. Record, Oct. 23, 1875, p. 720. 

8 Salleron, Pingaud. Art. Coude, Die. Encyc. Sci. Med., ser. 1, t. 21. 

a H. \\. Osborne, Bosp. Gazette, Nov. 29, 1879, p. 613. 

10 T. Pt. Varick, Med. Kecord, Nov. 1, 1867, p. 387. 

11 W. Wylie, Med. and Surg. Pvep., March 22, 1870, p. 200. 

12 Mason," Med. Pvecord, April 10, 1880, p. 307. 



<t>(3 DISLOCATIONS OF THE RADIUS AND ULNA. 

pronating and Bupinating the forearm. Free motion of the forearm in 
every direction was present, giving the impression of being attached to 
the arm Bolely by the soft parts. The projection of the internal condyle 
was out of all proportion to what is seen in cases of incomplete dislocation. 
The trochlea, coronoid depression, and the olecranon depression were 
distinctly recognized. Complete dislocation of the radius and ulna out- 
wards was diagnosticated, which diagnosis was corroborated by my friend, 
Dr. B. A. Watson, who was present and assisted in the reduction. 

"The patient was placed fully under the influence of ether, and mod- 
erate extension, combined with lateral pressure, effected the reduction 
without difficulty. The subsequent treatment consisted of rest and cold 
irrigation for a few days, followed by passive motion of the parts, which 
resulted in perfect recovery. The amount of inflammation wdiich fol- 
lowed the injury was exceedingly slight, due unquestionably to the prompt 
reduction of the dislocation." 

Dr. AVylie kindly permitted me to see the case which he has reported, 
and of which the two accompanying woodcuts (Figs. 299 and 300) are 

Fig. 299. 




c 

A. Radius: B. Olecranon process : C. Lower end of humerus. 

excellent illustrations. Dr. AVylie, who was at that time House Surgeon 
at the Long Island College Hospital, Brooklyn, in the service of Dr. S. 
1). Mason, relates the case essentially as follows: 

Edward Baker, aged thirty-eight, native of St. John's, Newfoundland, 
was engaged in a fishing enterprise in 1862. While fishing, standing 
on a staging formed of three-inch sticks laid crosswise three inches apart, 
lie fell with one arm raised, striking on the inner side of the elbow: 
at the Bame moment a barrel of fish, weighing two hundred and fifty 
ponnds, fell over, striking the arm about three inches above the external 
condyle. Upon rising he found the arm flexed at a right angle, pro- 
fited, and immovable at the elbow-joint. No attempt at reduction was 
ever made, nor was there any retentive apparatus applied. He put the 
arm in ;i sling, and after a couple of months he commenced using it a 
little. At the end of two years bis arm was sufficiently recovered to 
permit him to return to bis sailor life, which he followed up to six months 
ago, when he was admitted to the Long Island College Hospital, for 
other injuries. 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 767 

At the present time, seventeen years after the accident, the inner 
border of the olecranon process rests upon the external border of the 
humerus, above the external condyle, where, probably, an articular facet 

Fig. 300. 




The same. Arm nearly extended; the lower end of the humerus projecting below. 

has been developed. Just anterior to and to the inner side of this is the 
head of the radius, which can be recognized by sight, but more surely 
identified by touch. The internal condyle of the humerus projects 
greatly, and the trochlea can be distinctly felt. When extended, the 
radial border presents a gentle outward inclination from the elbow down. 
This may be greatly increased or diminished by manipulation. This 
extremity is one and three-quarters of an inch shorter than the other. 
(This is my own measurement, and differs a little from that given by 
Dr. "Wylie.) The patient has full control of this limb, can flex or extend, 
pronate or supinate it nearly as well as the other, and he thinks it is in 
every particular as serviceable as the other. 

Causes. — This accident has been produced generally either by a fall 
upon the hand or upon the elbow. In the latter case, it has been occa- 
sionally noted that the force of the concussion was received upon the 
internal portion of the elbow. 

Pathological Anatomy. — Two varieties of this accident have been 
recognized ; one in which the sigmoid fossa of the ulna is situated exter- 
nally and above the epicondyle, and one in which the sigmoid cavity 
embraces the epicondyle externally or is situated below it ; while the 
head of the radius is carried forwards by the resistance offered by the 
pronator muscles. 

Symptoms, — There is usually little or no difficulty in recognizing the 
nature of this dislocation, since the articular projections are easily felt 
and seen beneath the integuments. The deformity is very marked, and 
in the case of the supra-condyloid dislocation, the arm is shortened, the 
forearm is flexed and rotated inwards, and the motions of the joint are 
limited; while in the infra-condyloid variety, the forearm is very little 
or not at all shortened; it is flexed also, and the pronation is more 
extreme. 

Prognosis. — In most of the examples reported, the reduction has been 
effected, and the functions of the arm have been restored ; and even 
when not reduced, the usefulness of the arm has not been diminished in 
such a degree as might naturally have been expected. In the case of 



768 



DISLOCATIONS OF THE RADIUS AND ULNA. 



Baker reported above, the arm seemed after the lapse of seventeen years 
to be aa useful as before. 

Treatment. — Extend the forearm upon the arm, with the hand in a 
position of forced supination, and make traction ; and at the same time 
make direct pressure with the thumbs upon the projecting point of the 
ulna. In case the dislocation is infra-condyloidian, the hand may be 
maintained in a position of pronation during this procedure. 



(b) Incomplete Outward Dislocations. 

Incomplete dislocations must, however, in this case be regarded as 
typical ; but even these are by no means frequent. 

Causes. — A careful examination of a large number of recorded exam- 
ples, and of those which have come under my own eye, renders it certain 
that a majority of these accidents result from a blow received directly 
upon the inner side of the forearm or upon the outer side of the humerus, 
or from the action of two forces pressing in an opposite direction. Of 
course, these forces must act upon the bones somewhere in the neighbor- 
hood of the elbow-joint. Occasionally it has been produced by a fall 
upon the hand ; sometimes by a violent twist of the arm, as when the 
hand is caught in machinery ; and in other cases it has been found con- 
secutive upon a dislocation backwards, being pro- 
Fig. 301. duced in the attempts made to accomplish reduction 

of this latter form of dislocation. 

Pathological Anatomy. — In most of the exam- 
ples of simple incomplete outward dislocation of the 
forearm, the great sigmoid cavity of the ulna still 
embraces the lower end of the humerus ; but instead 
of reposing upon the trochlea fairly, it is carried 
outwards half an inch or more, so as to rest its cen- 
tral crest upon the depression which separates the 
trochlea from the lesser or radial head of the hume- 
rus. If the annular ligament remains unbroken, 
the radius is displaced in the same direction and to 
the same extent. 

Occasionally, however, where the violence has 
been greater, the Central crest of the great sigmoid 
cavity rests fairly upon the condyle, or upon the 
articulating surface of the humerus where the head 
of the radius was formerly applied, and the disloca- 
tion approaches more nearly to the character of a 
complete dislocation. At the same time, owing per- 
haps to the resistance afforded by the skin, or some 
of the ligaments, the head of the radius may be 
thrown either forwards or backwards, so as to be 
out of line with the ulna. Such a displacement 
generally implies a rupture of the annular ligament. 
We have now only to suppose the action of a more 
considerable force in the same direction to render the dislocation com- 
plete ; in which case the upper end of the radius is sometimes thrown 




Most frequent form 
of incomplete outward 
dislocation of the fore- 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 769 

completely forwards, and its head may even be found resting in front of 
the ulna, occasioning an extreme pronation of the forearm and hand. 

The anconeus and brachialis anticus are the only muscles in either of 
these dislocations whose fibres are generally much disturbed ; the biceps 
and triceps being only made to traverse the articulation a little more 
obliquely. 

In examples of fracture of the external condyle, the condyle being 
carried outwards, the radius may remain in contact with the trochlea, 
and the ulna may accompany it in this outward displacement ; but this 
must be regarded as a fracture rather than as a dislocation. 

Denuce, Malgaigne, A. Cooper, and others have preferred to speak of 
the dislocation backwards and outivards as a distinct form or species of 
dislocation. I prefer to regard it as only a variety of the outward dis- 
location, since it may, and no doubt often does, occur consecutively upon 
a simple incomplete outward dislocation ; and if the dislocation outwards 
is complete, the bones of the forearm can scarcely fail to be drawn more 
or less upwards. Sometimes also it has been consecutive upon a simple 
backward dislocation, or upon unsuccessful attempts at reduction where 
the form of dislocation was originally backwards ; yet, as it does not so 
naturally follow upon a complete backward dislocation as upon a complete 
outward dislocation, I find sufficient reason for studying its mechanism 
in this place. 

The beak of the olecranon process not only, but a large portion of 
the body of this process, now lies above and behind the condyle : the 
brachialis anticus becomes more stretched, if not actually torn ; and the 
biceps is laid against the articulating surface of the humerus ; but the 
triceps becomes again relaxed ; as in simple dislocation backwards and 
upwards. 

In all these dislocations the capsular ligaments are more or less exten- 
sively torn, but the principal arteries and nerves do not generally suffer 
greatly, if at all. 

Symptoms. — The forearm is usually flexed to about the same angle at 
which I have found it in dislocations backwards ; once I have found it 
nearly or quite straight ; occasionally it is flexed to a right angle. In 
all the cases seen by me the forearm has been pronated, and the elbow- 
joint has been very immovable. The most striking diagnostic sign, 
however, consists in the unnatural form of the elbow-joint, which is so 
remarkable as not to be easily misunderstood. The internal condyle 
of the humerus (epitrochlea) projects strongly to the inner side, leaving 
a deep depression below; while upon the other side, the head of the 
radius, with its cup-like extremity, can be distinctly felt, and made to 
rotate outside of its socket. The olecranon process, driven from its fossa, 
projects more or Less posteriorly, and even the fossa itself may sometimes 
be plainly felt. 

A girl, twelve years old. had fallen upon the inside of her elbow, pro- 
ducing an incomplete dislocation outwards of the forearm. I saw her 
within half an hoar. The forearm was bent upon the arm about fifteen 
degree.-. and immovably fixed. The head of the radius could be distinctly 
felt external to and a little in front of the outer condyle, while the ole- 
cranon process of the ulna, which rested upon the hack and outer surface 

40 



770 DISLOCATIONS OF THE RADIUS AND ULNA. 

of the humerus, was loss distinctly felt than in the opposite arm. The 
inner condyle projected sharply to the inside, and the olecranon fossa 
was plainly felt with the fingers. The child was suffering very little 
pain. 

Seizing the wrist with my right hand and the lower end of the humerus 
with the left, and making moderate extension in these opposite directions, 
the hones easily, and after only a moment's effort, resumed their places. 
Her recovery was rapid and complete. 

James O'Keil, ret. 16, was admitted to Bellevue Hospital in Dec. 1865, 
with a partial dislocation caused by the kick of a horse, the blow having 
been received on the ulnar side of the forearm near the elbow-joint. 
"When he came under my notice the dislocation had existed three weeks. 
I found the head of the radius reposing upon the radial and posterior side 
of the humerus. The ulna was displaced one inch to the radial side. 
The forearm was not at all, or but very slightly, flexed upon the arm. 
The natural deflection of the forearm to the radial side w r as a little ex- 
aggerated : forearm pronated : elbow-joint admitting of a little motion ; 
but motion caused great pain. 

This patient was not in my service, and I have not learned the result 
of the attempt at reduction. 

If the dislocation is complete, the position of the arm is usually the 
same, but the pronation of the hand is greater, and the projection of the 
inner condyle more striking. 

If now the bones, by a continuance of the original force, or by the 
action of the triceps, are drawn upwards also, the arm becomes a little 
more flexed, and the olecranon process more prominent, while the length 
of the whole limb is sensibly diminished. 

Prognosis. — In recent cases, and where no complications exist, the 
reduction is generally easily effected ; and M. Thierry claims to have 
reduced an outward and backward semi-luxation after eight months. A 
patient of whom Debruyn has spoken was not so fortunate. On the 
16th of April, 1841, a lad, aet. 18, fell upon the palm of his hand and 
semi-luxated both bones outwards and backwards; on the following 
morning a surgeon attempted to reduce the dislocation, and the attempt 
was repeated on the next day by another surgeon; but on the day fol- 
lowing this last attempt, gangrene ensued in consequence of the great 
violence employed by the surgeons, and although the limb was amputated, 
the patient died. The autopsy showed that both the brachial artery and 
the medial] nerve were torn asunder, and that the tendons of the biceps 
and the brachial is anticus were slipped behind the outer condyle, prob- 
ably having been thrown into this position during the violent twistings 
to which the arm had been subjected. 1 

I have seen three examples of semi-luxations upwards and outwards 
which the medical attendants had failed to reduce. The first was in the 
case of a lad. William Kinkaid, fourteen years old, who had fallen from 
a wagon and struck upon the palm of his left hand. The surgeon who 
was immediately called made extension, and supposed that the reduction 
was accomplished. The lad was brought to me a few months after the 

1 Denuce. op. cit. , p. 103. 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 771 

accident. The arm was slightly flexed, and neither prone nor supine. 
There existed only a slight motion at the elbow-joint. I did not think it 
worth while to make any attempt at reduction. Several years after this, 
in the month of February, 1859, I had an opportunity of examining the 
arm again. He had now recovered considerable motion in the joint, but 
he could not tie his cravat Pronation and supination were perfect. 

In the second example, a lady, ret. 33, had fallen upon the inside of 
her elbow, and reduction not having been accomplished, I found her, 
nine weeks after the accident, with scarcely any motion at the elbow- 
joint, and complaining of a numbness in the forearm and hand. 

The third instance of unreduced semi-luxation I will relate more at 
length : 

Francis Banfield, aged twenty-two years, a resident of Alleghany 
County, X. Y., on the 31st of September, 1857, fell from the sweep of 
a threshing-machine to the ground, a distance of about five feet, striking 
upon the palm of his hand, his arm being extended in front of him. On 
rising, he found his arm forcibly flexed and abducted. He straightened 
it without difficulty, and it assumed the position it now occupies. A 
physician was called and saw the patient an hour and a half after the 
accident, who pronounced it a case of dislocation of the radius and ulna, 
and made efforts at reduction, which he continued from 8J A. M. until 2 
p. M.j a period of five and a half hours, to no purpose, when he aban- 
doned the attempt. During the attempt at reduction, the extension was 
made at times with the arm flexed, and at others extended. At 9 p. M. 
another physician was called, who made efforts at reduction until 3 A. M., 
upwards of six hours, at which time he also abandoned the attempt. On 
the third day another physician, the patient being under the influence 
of ether, made efforts at reduction for twenty minutes, when he pro- 
nounced it in place, and applied a bandage. From the patient's account, 
the arm was swollen to such an extent as to render this point difficult to 
determine. On the fifth day the first physician was called, and, believing 
that he discovered a grating, pronounced it a fracture of the external 
condyle. 

Four months after the accident, when the patient applied to me, the 
limb presented the following appearances: The "forearm extended upon 
the arm ; looking at the limb along its radial margin, we notice a gentle 
outward inclination of the forearm from the elbow down, but by manipu- 
lation this may be greatly increased ; the power of pronation and supi- 
nation is not affected ; the inner condyle projects an inch to the ulnar 
Bide : the head of the radius, completely removed from its socket, projects 
to an equal extent on the radial side. The top of the olecranon process 
is an inch higher than the top of the inner condyle, so that the radius 
and ulna are carried upwards as well as outwards." 

I believe that the external condyle was not broken, as in thai case the 
arm would be permanently deflected outwards to a much greater extent. 
For. although this arm may be deflected outwards by the surgeon to an 
angle of 135°, still the degree of mobility which exists would he adverse 
to the supposition of its being a fracture of the external condyle. The 
condyle- also can be plainly felt in their natural situations, which would 



I I'l DISLOCATIONS OF THE RADIUS AND ULNA. 

not be the case if a fracture of the external condyle existed. The 
patient was advised not to submit to any further attempts at reduction. 

The following will serve as an illustration of a recent accident of this 
character: 

John Collins, of Buffalo, aet. 8, fell while wrestling, his companion 
falling upon his arm. I found the forearm slightly flexed, pronated, and 
both radius and ulna thrown over to the radial side and carried upwards. 
Pressing firmly upon the radius from the outside, the bones assumed 
suddenly the position of a backward and upward dislocation, from which 
position they were readily reduced to their original sockets by simple 
extension. 

Treatment. — In relation to the treatment of these accidents I have 
little to add to what has already been said of the treatment of dislocations 
backwards. The reduction, if effected at all, has generally been accom- 
plished by moderate extension, or by extension combined with lateral 
pressure. If the head of the radius is in front of the humerus, or of the 
ulna, the hand should be first supined, and then the extension should be 
applied. In some cases the reduction has been effected by placing the 
knee in the bend of the elbow and flexing the forearm, while the surgeon 
was making extension from the hand. 

§ 3. Dislocations of the Radius and Ulna Inwards (to the Ulnar Side) ; 
always Incomplete. 

This form of dislocation has generally been considered as much more 
rare than the incomplete dislocation outwards, a fact which may perhaps 
find a sufficient explanation in the peculiar form of the trochlea, the inner 
half of which rises much higher than the outer, forming thus an elevated 
inclined plane, over which the articulating surface of the ulna must rise 
before the dislocation can occur. Hahn and Sprengel have, however, 
observed the incomplete inward dislocation more often than the incom- 
plete dislocation outwards. 

Like the opposite dislocation, the typical form of the accident is that 
in which the displacement is incomplete; indeed, no example of a com- 
plete inward dislocation has, I think, been yet recorded. 

Causes. — A fall upon the hand or forearm, a blow upon the radial 
side of the forearm near its upper end, or upon the ulnar side of the arm 
near its lower end, a violent wrenching or rotation inwards, of the fore- 
arm, arc among the causes which may occasion this dislocation. 

J } <ii!ioio(jical Anatomy. — The ridge which divides antero-posteriorly 
the greater sigmoid cavity of the ulna, having been driven over the ele- 
vated inner margin of the trochlea, falls down upon the epitrochlea, so 
a-, in some sense, to embrace it instead of the trochlea; while the head 
of the radius passes inwards also, and is made to occupy the trochlea, 
from which the ulna lias escaped. Generally the head of the radius is 
found in the same line with the ulna (Fig. 302), but it may suffer a dis- 
location and be found a little in advance of the ulna, or possibly a little 
back of the ulna. 



DISLOCATIONS OF KADI US AND ULXA INWARDS. 773 



Pig. 302. 



I choose also to regard the semi-dislocations inwards and upwards as 
onlv a variety of the semi-dislocation inwards: in which form of the 
accident the coronoid process of the ulna is thrust upwards above the 
epi condyle, and the head of the radius occupies 
the olecranon fossa, or rests upon the back of the 
humerus somewhere in this vicinity. 

In addition to the injury suffered by the liga- 
ments and muscles, the ulnar nerve in both 
varieties of inward dislocation is peculiarly 
liable to contusion, in consequence of its being 
crushed between the olecranon process and the 
epitrochlea. 

The attention of the reader must again, as in 
examples of fractures of the external condyle, 
be called to the fact that, in fractures of the 
internal condyle the radius and ulna are apt to 
suffer a lateral displacement also ; but that these 
examples are more properly to be considered as 
fractures rather than dislocations. 

Symptoms. — If the displacement is only in- 
wards, the olecranon process can be felt pro- 
jecting upon the inner side, and completely con- 
cealing the epicondyle ; while the head of the 
radius, having abandoned its socket, may be felt 
indistinctly in the bend of the arm. The external 
condyle (epicondyle) is remarkably prominent. 
The forearm is generally more or less flexed. 
The natural outward deflection of the forearm is 
also lost, or it may be even inclined slightly in- 
wards. This phenomenon is explained by the position of 'the epicondyle, 
upon which the greater sigmoid cavity now rests, allowing the ulna to 
overlap a little upon the humerus ; rendering the forearm actually some- 
what shorter along its ulnar margin, although the head of the radius 
may still occupy the summit of the trochlea. 

If the bones are displaced upzvards, as well as inwards, a consider- 
able shortening is declared, and the head of the radius may now be felt 
behind the trochlea, or over the olecranon fossa. In three of the four 
examples seen by Malgaigne, all of them ancient, the forearm was in a 
state of supination. 

August 25th, a girl, set. 5, fell from a swing, striking upon her right 
elbow. A physician was called, who supposed it to be a fracture. Five 
weeks later it was seen by Prof. T. F. Prewitt, of St. Louis, Mo. The 
forearm was flexed, and could not readily be extended beyond a right 
angle; it occupied a position midway between pronation and supination 
ordinarily, but could be supinated and pronated perfectly. The olecra- 
non proeess was on a line with the extreme point of the inner epicondyle, 
and the head of the radius could bo felt below the olecranon fossa. A 
finger could be pressed readily into the fossa. A small, sharp spiculum 
of bone had been torn off. and lav loose over the external condyle, which 




Most frequent form of in- 
complete inward dislocation 
of the forearm. 



m4 DISLOCATIONS OF RADIUS AND ULNA. 

a\;i- very prominent. Attempts were made by Dr. Prewitt to reduce the 
dislocation under the influence of an anaesthetic^ but without success. 1 

Tin 1 following example of this dislocation, unreduced after the lapse 
of fourteen years, is reported to me by Dr. T. H. Squier, of Elmira, 
N. Y. : Thomas Cook, now in his nineteenth year, was four years and ten 
months old when he fell from a pile of boards about as high as a man's 
shoulder. According to his statement, given at the time, his right arm 
caught between the boards, and, in falling, he turned a somersault. The 
mother, to whom the child immediately ran, grasped his arm which he 
said was broken, and found that it would roll and turn in various ways. 
When the surgeon arrived, three hours afterwards, the arm was very 
much swollen, and the accident was supposed to be a fracture. At pres- 
ent the flexion and extension are perfect. The forearm has an inward 
deflection of a hand's breadth more than the other. The power of prona- 
tion is complete, but the forearm and hand cannot be supinated entirely. 
The external condyle is very prominent, but the internal is almost hid 
by the olecranon, which projects inwards nearly as far as the point of the 
epi condyle. The finger can be laid in the olecranon fossa behind, and 
all the back part of the trochlea can be distinctly traced. By flexing 
the forearm slowly, as it approaches a right angle, the tendon of the tri- 
ceps may be felt, lodged, as it were, on the back part of the point of the 
epicondyle ; and by continuing the flexion, the tendon suddenly slips 
over this point and places itself on the anterior aspect of the arm. When 
the forearm is fully flexed, the tendon is advanced full three-quarters of 
an inch in front of the epicondyle. The arm is very serviceable, but 
invariably pains him after a hard day's work. 

Prognosis. — Malgaigne was unable to reduce the bones in a recent 
case of incomplete internal dislocation which came under his own notice. 
Triquet succeeded in a child seven years old, on the fifteenth day, after 
many trials ; but the movements of the elbow-joint were never restored. 
Debruyn succeeded on the fifth day, but not without difficulty; Prewitt 
failed at the end of five weeks; the case reported by Squier was mis- 
taken for a fracture, and no attempt at reduction was made ; and in a 
case seen by Velpeau, reduction was easily accomplished, and on the 
eighth day the patient was dismissed. 2 

Of the four examples of inward, backward, and upward dislocation 
seen by Malgaigne, not one was ever reduced ; but as the history of them 
all is not complete, it is by no means to be inferred that the reduction 
could not have been easily accomplished, at least in some of them, at the 
first. Nor, with such imperfect details before us, can we understand 
fully wliat complications may have existed, such as would perhaps render 
these exceptional, rather than illustrative examples. 

One of these patients had a completely anchylosed elbow at the end of 
two years, but pronation and supination were preserved. In the case of 
another, however, even flexion and extension were as perfect as in the 
normal condition. 

Treatment. — The indications of treatment are the same as in semi-dis- 
locations outwards, with only such slight modifications as the judgment 

I" Airt. St. Louis Courier of Med., Jan. 1879, p. 43. 
- Denuc£, op. cit.. ]>]>. ] ".4-156. 



DISLOCATIONS OF RADIUS AND ULNA FORWARDS. 775 

of everv surgeon must naturally suggest. I prefer to employ by way of 
illustration the example diagnosticated by Velpeau. 

On the 10th of May, 1848, Alexandrine Guyot, ret. 22, entered the 
Hospital of La Charite with an incomplete inward dislocation of the fore- 
arm, which had just occurred. The hand and forearm were in a state of 
forced pronation, half-flexed, and the whole limb from the elbow down- 
wards was deflected inwards. There were present also all the other 
usual signs of this dislocation, and Velpeau had no doubt as to its true 
character. 

In order to accomplish reduction, one assistant made counter-extension 
upon the arm, while a second made direct extension upon the forearm. 
At first the tractions were made in the direction of the forearm (flexed 
and prone), but gradually the arm was straightened and supinated. 
Then the surgeon, seizing with one hand the superior extremity of the 
forearm, and with the other the inferior extremity of the arm, acted 
forcibly upon the two portions in opposite directions, and immediately 
the reduction was effected with a noise. 1 

§ 4. Dislocations of the Radius and Ulna Forwards. 

Sir Astley Cooper, Yidal (de Cassis), and others have denied that this 
dislocation was possible without a fracture of the olecranon process ; but 
Monin. Prior, Velpeau, Canton, 2 and Denuce have each reported one 

Pig. 303. 




E. Cai dislocation of the radius and ulna forwards. 



cit., p. 1 56. 
2 Dub. Quart. Journ. of Med. Sci., Aug. 1*00. 



7*6 DISLOCATIONS OF THE RADIUS AXD ULNA. 

example, also Wittlinger, Flaubert, Secrestan, and Cannin, 1 so that its 
existence may new be considered as established. 

The following is a summary of the facts in Velpeau's case: Alexan- 
drine Oarelli, set. 23, was knocked down by a carriage, on the first of 
July, 1848, the wheel passing over the right arm. The arm was found 
in a right-angled position, and it could neither be flexed nor extended; 
the forearm was strongly supinated; the projecting angle usually made 
by the olecranon process was replaced by the irregular extremity of the 
humerus : the forearm was shortened upon the arm ; the head of the 
radius resting in the coronoid fossa, and the olecranon process being also 
carried upwards and a little outwards. Reduction was easily accom- 
plished, and the patient left on the nineteenth day, with only a slight 
remaining stiffness in the joint. 2 

A case is reported to have come under the observation of Mr. J. W. 
Langmore, House Surgeon at the University College Hospital, London. 
It was occasioned by a fall upon the elbow. The reduction of the ulna 
was easily accomplished by placing the knee in the bend of the elbow 
and flexing the arm. The radius was then reduced by pressure and ex- 
tension. 3 

( Impel has reported a case of dislocation forwards and outwards, which 
he readily reduced soon after it occurred, while Colson, Leva, Ancelon, 
and Guyot have each reported one example of sub-luxation forwards, in 
which the extremity of the olecranon process has been found resting 
upon the extremity of the humeral trochlea. 4 

In a case of incomplete dislocation forwards mentioned by Date 5 the 
internal condyle was broken. 

The fracture of the olecranon as accompanying this accident, has, ac- 
cording to Poinsot, only been observed in six cases, namely, by Richet, 
Velpeau, Guerin, Morel-Lavallee, and Guerre. In the latter case, ac- 
cording to Pingaud, the dislocation was easily reduced, and the result was 
a very useful limb. 

Causes and Mechanism. — This accident seems to have been, in most 
cases, caused by a fall upon the elbow while the forearm was forcibly 
flexed. In Date's case, however, a boy 14 years old, the fall was upon 
the palm of the hand. 

In case it is caused by a fall upon the elbow, with the arm in a posi- 
ti<»ii of forced flexion, the olecranon receives the impact, and this fact, 
aided perhaps by tortion and abduction of the forearm, drives the bones 
forwards. 

Patliological Anatomy. — In the case reported by Canton, amputation 
became necessary, and an opportunity was thus afforded to make a care- 
ful dissection of the parts involved in the injury. At the time of the 
accident the arm was in a position of forced flexion, with the forearm 
twisted upon the chest. 

The olecranon was found lying in front of the little head of the hume- 

1 Poinsot, op. fit., ]>. 989. 
I >enuc6, op. eit., ]». 110. 

w Yon Med. Record, March 1, 18G7. from the London Lancet. 

4 Deniw,'. ],. 1 -jo. 

5 Date, The Lancet, 1872, vol. 2, p. 97. 



DIVERGING DISLOCATIONS OF RADIUS AND ULNA. iii 

rus. the radius was in a position of supination, preserving its normal 
relations with the ulna. The anterior ligament was torn, as were also 
the posterior and lateral ligaments. The annular and oblique ligaments 
were intact. The triceps was torn from its insertions. The two external 
radial and most of the muscles originating at the epicondyle, were more 
or less torn. The biceps and brachialis anticus were in a state of tension. 
The larger vessels were unbroken. The ulnar nerve was torn opposite 
the condyle. The median nerve had suffered only slight lesions. 

Treatment. — If the dislocation is complete, and the forearm is short- 
ened and flexed upon the arm, the redaction should first be attempted by 
violent flexion, or by flexion combined with extension from the wrist, 
and counter-extension from the lower portion of the humerus. If the 
dislocation is incomplete, and the forearm is extended upon the arm, the 
reduction may be readily accomplished by extension alone, or by moderate 
flexion. 

Dislocation of the Radius and Ulna Forwards, with Complete Retro- 
version of both Bones. — Maisonneuve 1 has reported a case in which both 
bones being dislocated forwards, the ulna was turned upon itself, so that 
its sigmoid cavity embraced the articular extremity of the humerus. The 
patient, a woman aet. 43, had fallen upon the internal margin of the 
humerus. The inferior extremity of the humerus projected posteriorly, 
covered only by the skin. The triceps, slightly stretched, was carried 
outwards and forwards, and lay in front of the condyle. The olecranon, 
unbroken, was in front of the trochlea ; its great sigmoid cavity embraced 
the articular pulley. The radial cup was entirely hidden. The forearm 
was forcibly pronated. 

Reduction was effected by carrying the forearm outwards, by which 
the olecranon was disengaged, and the cup of the radius presented itself 
externally : continuing to press the forearm outwards, the olecranon now 
abandoned the trochlea, embraced the condyle, and then slid outwards. 
The forearm at once took the position of supination, and the great sig- 
moid cavity again presented forwards, passing behind the humerus. The 
dislocation, having thus been transformed into a backward dislocation. 
was easily reduced. 

I 5. Diverging Dislocations of the Radius and Ulna. 

(a) Dislocations of the Radius Forwards, and Ulna Backwards. 

This accident was first recognized, according to Malgaigne, by M. 
Michaux and M. Bulley in 1841, when each of these gentlemen met with 

Michaux's patient was a man. 44 years old, who had fallen eight feet, 
striking upon his elbow while it was carried away from his body. At 
first the dislocation of the radios was not recognized, but having reduced 
the ulna by traction, he discovered the head of the ulna in front, which 
was finally reduced by direct pressure made upon it with the thumb. 

M. Bufiey's patient was a male also, aet. 28, who had been thrown 

1 Maisonneuve, Gaz. dee JI ■: .. 1867, No. 37. Poinsot, op. cit.. p. Ti44. 



778 DISLOCATIONS OF THE RADIUS AND ULNA. 

violently upon the palm of his hand. The forearm was slightly flexed, 
and could not be moved from this position without causing great pain. 
The coronoid process rested in the olecranon fossa, and the head of the 
radius in the coronoid fossa. With slight traction the ulna was reduced, 
and afterwards the radius was reduced by methodic processes. 

M. Mayer reported a case which was not recognized until the four- 
teenth day. and then he found himself unable to reduce it. 1 

Denuce mentions these three cases and no others. 

Tillaux 3 also saw a case, of eight days' standing, in a girl 22 years of 
age, which he was unable to reduce. Minich, 3 in a case which came 
under his observation, reduced the ulna easily, but did not succeed in 
reducing the radius until he had made several attempts. Minich, in his 
report of this ease, refers to three other cases as having been seen by 
Vignolo, Bardeleben, and Chevalier. 

Poinsot has also reported a case seen by his colleague Arnozan, which 
was accompanied with a fracture of the internal condyle, but which for 
that reason cannot be considered as representing a true dislocation. 

To these cases I will add the case reported by Dr. Erskine Mason as 
having been seen by himself and Dr. Whybrew. The man was 28 years 
old. and the accident had happened in a fall when he was intoxicated. 
He had supposed it was a sprain, and these gentlemen were not consulted 
until the eighteenth day. The character of the dislocation was apparent, 
but they could not positively determine but that a portion of the external 
condyle had been broken off; there was, however, no crepitus. The 
limb was nearly straight, and would admit of but slight flexion. Under 
ether, prolonged efforts at reduction were made, with the result of finally 
reducing the ulna, but the radius remained unreduced. 4 

(b) Transverse. Ulna Inwards, and Radius Outwards. 

The following case, reported by Warmont, was presented in the service 
of Guersant, 5 at the Hopital des Infants, June 29, 1854. A boy, 15 
years old, had fallen a few feet, striking upon the palm of his left hand. 
The elbow was enormously swollen ; its transverse diameter was much 
increased, while the antero-posterior seemed flattened. No abnormal 
protrusion existed in front, but externally the head of the radius pro- 
jected, ha vim:- ascended along the external border of the humerus. The 
olecranon was displaced inwards, so that the inner condyle was em- 
braced by the great sigmoid cavity. Between the bones of the forearm, 
thus separated, almost the whole of the articular surface of the humerus 
was Lodged. The forearm was semiflexed, and semipronated. 

(c) Oblique. Ulna Backwards, and Radius Outwards. 

Samuel Withe" has described the case of a boy jet. 13, who had fallen 
violmtly upon his left elbow. " The condyles of the humerus protruded 

1 Michaux, Bulley, Mayer. From Malgaigne, Paris ed., 1855, vol. ii. p. 631. 

2 Tillaux, Gaz. dee Bdp., 1877, No. 99. 
* Minich, Lo Sperimentale, 1880, fas. 6. 

Mason and Whybrew, Med. Rec., April 10, 1880, p. 397. 
Warmoi t, Rev. Med.-Chir., t. 16, p. 303. 
r - AYithe, A. Cooper, (Euv. Chir. ed. cle Chassaignac, et Eichelot, Paris, 1837. 



DISLOCATIONS OF THE WRIST. 779 

through the skin at the internal portion of the articulation, exposing 
entirely the trochlea of the humerus : the ulna was dislocated backwards, 
and the radius outwards."' Reduction was easily effected and a satis- 
factory result ensued. 

(d) Oblique. Ulna Forwards, and Radius Outwards. 

Maimer Mens 1 witnessed this dislocation in a man who had struck 
his elbow violently against a wooden obstacle while it was in a position 
of forced flexion. The ulna was displaced forwards without fracture of 
the olecranon, the radius was completely displaced outwards. Reduction 
was easily effected by traction and pronation. The cure was effected in 
two months. 



CHAPTER XI. 

DISLOCATIONS OF THE WRIST , RADIO-CARPAL). 

Regarded as an accident of not unusual occurrence by Hippocrates, 
J. L. Petit, Duverney, Boyer, and by most if not all of the older writers, 
it- frequency began to be questioned by Pouteau, and finally its exist- 
ence was almost absolutely denied by Dupuytren, who remarks : " I have 
for a long time publicly taught that fractures of the carpal end of the 
radius are extremely common ; that I had always found those supposed 
dislocations of the wrist turn out to be fractures; and that, in spite of 
all which has been said upon the subject. I have never met with, or heard 
of. one single well-authenticated and convincing case of the dislocation 
in question." Dupuytren subsequently declared that he would not posi- 
tively deny the possibility of the accident, yet that ''it must at least be 
admitted that the accident is an extremely rare one." Wishing to explain 
this infrequency. he says: "In examining the structure of the soft parts. 
one cannot fail to perceive that it is not the ligaments which prevent the 
displacement of the articular surface forwards, but that this effect is es- 
pecially due to the multitude of flexor tendons, deprived as they are at 
this point of all the fleshy parts, and reduced to the simple fibrous tissue 
which composes them. These tendons are bound together beneath the 
anterior annual ligament of the wrist, and thus offer so efficient a re- 

ce that severe falls are insufficient to tear them through : the hand 
i- forced into a state of extreme extension, and the tendons are firmly 
applied on the anterior part of the radio-carpal articulation. If the ex- 

d i- still farther augmented, the wrist-joint is yet more closely 
clasped by these parts, and their power of resistance is incalculable; I 
am convinced that a force equivalent to one thousand pounds weight 
would be inadequate to overcome it: and the known power of the tendo 
Achillis is sufficient to prove that tbi- computation is not exaggerated. 

1 Maimer Mons, Deut. Milit. Zeitschr., 1S77. Hit. 6 u. 9, p. 401. 



780 DISLOCATIONS OF THE WRIST. 

"The risk of dislocation backwards by a fall on the dorsal surface of 
the hand is equally precluded by the tendons of the extensor muscles. 
Their arrangemenl and relations at the back of the joint are similar; it 
is true, they are not quite so strong; but we must admit that their power 
of resistance is very considerable, when we take into consideration how 
they are inclosed in sheaths as they cross beneath the posterior annular 
ligament of the wrist. I have not alluded to the ulna, for it has really 
little or nothing to do with these movements, as it does not articulate 
(directly) with the hand. 

"To sum up, then, the extreme rarity of dislocation forwards or 
backwards is owing to the obstacles opposed by the flexor or extensor 
tendons." 

The opinion of such a writer as Dupuytren, whose experience was very 
great, and who described only what he had seen, is always entitled to 
profound respect; yet it has been the practice of nearly all who have 
made any reference to his opinions in this matter to speak of them lightly, 
and not a few have falsely represented him as saying that a dislocation 
was "impossible." The fact is, that surgeons do still constantly mistake 
fractures of the lower end of the radius for dislocations, as my own per- 
sonal observations can attest; and notwithstanding examples have been 
reported by Rene, Marjorlin, Padieu, Cruveilhier, Voillemier, Poinsot, 
Malgaigne, Scoutetten, Bransby Cooper, Fergusson, W. Parker, and 
others, yet the whole number of cases for which the distinction is claimed 
is, to this day, so inconsiderable as only to establish the value and accu- 
racy of Dupuytren's opinion that the " accident is an extremely rare 
one." But it is, perhaps, most remarkable, that while very few of these 
supposed examples have been permitted to be examined after death, in 
a large majority of the cases in which the autopsy has been made, the 
dislocation has been found to be complicated with a fracture, generally 
of the lower extremity of the radius or of the styloid apophysis of the ulna. 

The existence of a complication, however, does not render the acci- 
dent any the less a dislocation, although it may render the diagnosis 
more difficult, and modify somewhat the indications of treatment. A 
knowledge of the fact, also, that such complications have always been 
observed in the autopsy, may leave us in doubt as to what is the natural 
history of a simple uncomplicated dislocation, if, indeed, it does not 
warrant a suspicion that such a case never occurs. We shall, never- 
theless, after a careful analysis of the cases as they have been reported, 
and by a consideration of the anatomy of this articulation, be able to 
determine with some degree of accuracy, perhaps, what are, or what ought 
to he. the usual causes, signs, treatment, etc., of these accidents. 

Partial dislocations have also been frequently described by surgeons. 
I have never met with an example, but the following case, related to me 
by the patient himself. I believe to have been a case in point. 

Lewis ('.. of Buffalo, set. 18, by a fall upon his hand, broke the left 
forearm below the middle, and at the same time, as he affirms, partially 
dislocated the em-pal bones backwards. Dr. Spaulding, ofWilliams- 
ville. X. Y.. took charge of the limb, and pronounced it a fracture, 
with partial dislocation, and for more than a year after the accident the 
bones had a tendency to become displaced in the same direction. When- 



DISLOCATIONS OF THE WRIST. 781 

ever he attempted to lift even the weight of half a pound, with his hand 
supinated and his forearm extended horizontally, the lower end of the 
radius would spring suddenly forwards, and all power in the arm would 
be lost. When this happened, as it did quite often, he always reduced 
the bones himself, by simply pushing upon them in the direction of the 
articulation. 

Fourteen years after the accident, I examined the arm and found it 
in all respects perfect, except that the forearm was shortened about one- 
third of an inch, which shortening was due, no doubt, to the overlapping 
of the broken bones. 

I am unable to verify the accuracy of the statements made in the 
following paragraph; but as there seems to be no reason why they 
should not be accepted, it will be proper to give them a place in this 
treatise. * 

"According to Francis L. Parker, M.D., Professor of Anatomy in 
the Medical College of South Carolina {Trans. S. C. Med. Assoc), 
there are thirty-three cases of so-called dislocations of the wrist-joint on 
record (omitting the cases of W. Parker and Rene), including his own, 
viz.. case of dislocation of the wrist-joint backwards. Of these, twenty- 
three are said to have been dislocated backwards and ten forwards ; of 
this entire number only seven, five backwards and two forwards, are free 
from all objection. Of the twenty-six cases of doubtful or unsatisfactory 
dislocations, sixteen were complicated with fracture of one of the bones 
or processes connected with the joint : three were compound, three were 
incomplete, two were arthritic or pathological specimens, and two were 
objected to from other causes. Of the thirty-three so-called dislocations, 
the sex is recorded here in fourteen instances ; of these eleven were 
males and three were females. Of the seven cases classed as genuine 
ones, one post-mortem was made (case of M. Malle), which confirmed 
the diagnosis ; in six remaining cases the patients regained the use of 
the limb in a very short time, without a tendency to displacement or 
deformity. Of these seven cases accepted as genuine, two backward 
dislocations were produced, the force of the fall being received, in one 
instance, on the dorsum of the hand (Hamilton's) ; in the other upon 
the palmar surface (Parker's) ; in M. Malle's case, a forward displace- 
ment, the presumption is that the patient fell on the palm of his hand, 
but this is not definitely stated ; and in the four remaining cases this 
point is not specified. He lays down the following practical conclusion-. 
which may be derived therefrom: 1st. The wrist-joint may be dislocated 
backwards or forwards without fracture or a rupture of the integuments; 
both are extremely rare: the backward displacement is the most fre- 
quent. 2d. Cases of so-called dislocation of the wrist may be associated 
with fracture of the radius and ulna, or with either of these bones sepa- 
rately, with both styloid p >r either of them, or with fracture of 
the articulating surface of the radius; no instance has been recorded of a 
dislocation of this joint complicated with fracture of the carpal bono-. 
3d. Dislocation of the wrist backward- or forwards may ho complicated 
with rupture of the integuments anteriorly or posteriorly, or laterally, 
with or without fracture of the styloid processes." 1 

1 P. L. Parker, Med. Rec.. Nov. 1. 1-71. 



782 MSLOCATIOXS OF THE WRIST. 



- 1. Dislocations of the Carpal Bones Backwards. 

Causes. — The same casualty, namely, a fall upon the palm of the 
hand, which, as we have elsewhere noticed, produces frequently a frac- 
ture of the lower end of the radius, occasionally a dislocation of the 
radius and ulna backwards, at the elbow-joint, may also, it is believed, 
occasion sometimes a dislocation of the carpal bones backwards. In 
several of the cases reported, this cause has been assigned; but in the 
only example of simple dislocation which has ever come under my notice, 
and which I have every reason to believe was a simple dislocation unac- 
companied with a fracture, the carpal bones were thrown back by a 
fall upon the back of the hand. The following is a brief account of the 
case : 

The Rev. Stephen Porter, of Geneva, N. Y., ret. To, while walking 
with his son after dark, and holding in his right hand a satchel, slipped 
and fell. In the effort to save himself, and still retaining his grasp 
upon the satchel, his right hand struck the sidew T alk flexed, and in such 
a way that the whole force of the fall was received upon the back of the 
hand and wrist, thus throwing the hand into a state of extreme flexion. 
In less than twenty minutes he was at my house. No swelling had yet 
occurred, and the moment I looked at the wrist I said to him, " You 
have broken your arm ; so much did it resemble a fracture of the lower 
end of the radius. A further examination led me to a different conclu- 
sion. The palmar surface of the wrist presented an abrupt rising near 
the radio-carpal articulation, the summit of which was on the same plane 
and continuous with the bones of the forearm, and a corresponding eleva- 
tion existed upon the dorsal surface terminating in the carpal bones and 
hand ; the hand was slightly inclined backwards, but the fingers were 
moderately flexed upon the palm. To this extent the accident bore the 
features of a fracture of the radius ; but the hand did not fall to the 
radial side; the projections upon the palmar and dorsal surfaces were 
more abrupt than I had ever seen in a case of fracture, and which, if it 
were a fracture, would imply that the broken extremities had been driven 
off from each other completely; the most salient angles of these projec- 
tion- were abrupt, but not sharp or ragged: the styloid apophyses could 
be distinctly felt, and I was not only able to determine that they were 
not broken, but, by observing their relations to the palmar and dorsal emi- 
nences, it was easy to Bee thai these latter corresponded to the situation 
of the articulation. 

In addition to these evidences that I had to deal with a dislocation, 
and not a fracture, I had the testimony furnished by the reduction, 
which was not made, however, until by every possible means the diag- 
nosis was definitely Bettled. Seizing the hand of the gentleman with 
my own hand, palm to palm, and making moderate but steady extension 
in a straight line, the hones suddenly resumed their places with the usual 
sensation or sound accompanying reductions. There was no grating, or 
chafing, or crushing, nor was the reduction accomplished gradually, but 
suddenly. To test still further the accuracy of the diagnosis, I now 
pressed forcibly upon the wrist from before back, but without producing 



DISLOCATIONS OF THE CARPAL BONES BACKWARDS. 783 

any degree of displacement, nor could any crepitus still be detected. No 
splint was applied, and on the following morning Mr. Porter preached 
from one of the pulpits in the city, only retaining- his arm in a sling. 

Sixteen months after the accident, September 15, 1858, this gentle- 
man again called upon me, and I found the arm perfect in all respects, 
except that it was not quite as strong as before ; the lower extremity of 
the ulna was preternaturally movable, and occasionally he felt a sudden 
slipping in the radio-carpal articulation. 

Pathological Anatomy. — In the examples of compound or complicated 
dislocations, which have been exposed by dissections, the posterior and 
lateral ligaments have been found extensively torn, as also frequently 
the anterior ligament, with or without separation of the radial or ulnar 
apophyses : the extensor muscles torn up from the lower part of the fore- 
arm and displaced : the first row of the carpal bones lying underneath 

Fig. 304. 




Dislocation of the carpal bones backwards. (From Fergusson.) 

the tendons, and upon the bones of the forearm, sometimes having been 
carried directly upwards, sometimes upwards and a little inwards, and at 
other times upwards and outwards : the arteries and nerves have occa- 
sionally escaped serious injury, but more often they have been displaced, 
braised, or torn asunder. 

Such are, briefly, the pathological circumstances which may be sup- 
posed to exist, also, in a lesser or greater degree, in nearly all cases of 
simple dislocations. 

In compound dislocations, however, the muscles, or rather the ten- 
dons, are twisted, torn, and thrust aside, producing very extensive 
lesions among tin- deeper -tinctures of the forearm and hand before the 
integuments can 1"- made to yield. 

On the 2d of May, 1852, Silas Usher, aet. 54. had his righl arm 
caught between the bumpers of two cars, bruising the hand hum dislo- 
cating the carpal bone- backwards, the radius and ulna being tin-own 
forwards and pushed completely through the skin into the palm of the 
hand. Most of the flexor tendon- had been merely thrust aside, but one 
or two were torn asunder; the median uerve was torn off, but the radial 
and ulnar nerves were apparently uninjured, and there was do fracture. 



JS4 DISLOCATIONS OF THE WRIST. 

The patient being ;i temperate man, in perfect health, and the bones 
having been easily replaced by moderate extension, it was determined to 
make an effort to save the arm. The limb was therefore laid on a care- 
fully padded splint, and cool water lotions diligently applied. Phleg- 
monous erysipelas began to develop itself on the third day; and on the 
ninth, gangrene having attacked the limb, I amputated a little above the 
middle of the humerus. On the fourteenth day haemorrhage occurred 
suddenly from the stump, and when I reached him he was pulseless and 
dying. 

The result demonstrated the error of the attempt to save the limb 
without resection of the lower ends of the bones of the forearm. I 
will also add, that according to my later experience it would have been 
1 tetter, if an attempt were to be made to save the hand without resection, 
to have used warm instead of cold water, and when gangrene occurred, 
to have applied hot water, or water at a temperature of 105° or 110° F., 
either in the form of fomentation or a bath. 

Symptoms. — The usual signs have already been sufficiently stated in 
the example which I have given. The most important diagnostic 

marks are found in the abruptness 
Fig. 305. f the angles formed by the project- 

ing bones ; the relation of these prom- 
inences to the styloid apophyses; in 
the total absence of crepitus ; and in 
the reduction, which is accomplished 
easily, suddenly, and with a charac- 
teristic sensation. If a fracture com- 

Dislocation of the carpal bones backwards. plicates the accident, crepitus may 

also be present. It should be re- 
membered, moreover, that when the styloid process of the radius is 
broken, if the hand is moved backwards and forwards this process will 
move also, which might lead to the supposition that the radius was 
broken higher up, and that it was not a dislocation at all. 

Prognosis. — In compound dislocations the prognosis is exceedingly 
grave, unless the surgeon determines to resort to amputation, or, what 
is generally much preferable, to resection. In dislocations complicated 
with fracture of the posterior edge of the articulating surface of the 
radius ("Barton's fracture" 1 ), some difficulty may be experienced in 
retaining the bones in place; but when this fracture does not exist, the 
posterior margin of the articulation, considerably elevated above its an- 
terior margin, constitutes a sufficient protection against a redislocation in 
that direction. In all cases, also complicated with fracture, even of an 
apophysis, intense inflammation and swelling are likely to follow, and 
the danger of a permanent anchylosis is greatly increased. 

Treatment. — Extension in a straight line has generally been found 
sufficient to accomplish the reduction; to which may be added a slight 
rocking or lateral motion, if necessary. 

The reduction may be effected also by pressing the hand backwards^ 

1 Philadelphia Medical Examiner, 1838. 




DISLOCATIONS OF THE CARPAL BONES FORWARDS. 785 

while the surgeon pushes the carpus downwards from behind and above, 
in the direction of the articulation. 

Unless a tendency to displacement exists, no splints or bandages of 
any kind ought to be applied, but the case should be treated by rest and 
fomentations until all danger from inflammation has passed. 

§ 2. Dislocations of the Carpal Bones Forwards. 

The causes, mechanism, symptoms, pathology, treatment, etc., of this 
accident resemble in so many points those of the preceding dislocation, 
with only the differences necessarily due to a change in the direction of 
the bones, that I find it not worth while to do more than to relate one sin- 
gle example, contained in Bransby Cooper's edition of Sir Astley's work 
on Fractures and Dislocations. The case did not come under the ob- 
servation of Mr. Cooper himself, but was related to him by Mr. Haydon, 
a surgeon residing in London. It is especially interesting as furnishing 
an example of a dislocation of both wrists at the same moment, and from 
similar causes, but in opposite directions. 

Fig. 306. Fig. 807. 




Dislocation of the carpal bones forwards. Dislocation of the carpal bones forwards. 

A lad, aged about thirteen years, was thrown violently from a horse 
on the 11th of June, 1840, striking upon the palms of both hands and 
upon his forehead. The left carpus was found to be dislocated back- 
wards, the radius lying in front and upon the scaphoides and trapezium. 
The right carpus was dislocated forwards, the radius and ulna projecting 
posteriorly, and the bones of the carpus forming an "irregular knotty 
tumor terminating abruptly" anteriorly. 

A very careful examination was made to determine what parts came 
in contact with the resisting force, but although the palms of both hands 
were extensively bruised, there was not the slightest bruise on the back 
of either hand. Nor were the gentlemen present able to find any evi- 
dence whatever that the dislocation was accompanied with a fracture. 
'• Moreover," says Mr. Haydon, "we were strengthened in our opinion 
that this was ;i case of dislocation, unattended with any fracture, because 
the dislocations appeared so perfect; the two tumors in each member so 

50 



786 DISLOCATIONS OF THE LOWER END OF ULNA. 

distinct; the reduction so complete; the strength of the parts after re- 
duction bc great; and lastly, by the vory trifling pain felt after reduction, 
for within an hour after, the patient could rotate the hand, and supinate 
it when pronated — this could not, we believe, have been done had there 
existed a fracture." 



CHAPTER XII. 

DISLOCATIONS OF THE LOWER END OF THE ULNA (INFERIOR 
RADIO-ULNAR). 

In connection with fractures of the lower end of the radius this acci- 
dent is not very uncommon. I have myself met with it under these cir- 
cumstances several times; but without a fracture of the radius it is quite 
rare. Dupuytren met with but two cases in his long and extensive prac- 
tice. Sir Astley Cooper does not record a single instance, and many 
surgeons affirm that they have never seen the dislocation in question, 
uncomplicated with a fracture of the radius. 

§ 1. Dislocations of the Lower End of the Ulna Backwards. 

Malgaigne never met with a case, but he refers to eleven or twelve 
examples which had been reported up to the time he wrote. I have met 
with three cases. 

Causes. — Duges mentions the case of a little girl in whom the accident 
occurred in both arms, but at different periods, by being lifted by the 
hands. One of the patients seen by Desault, a child five years old, had 
the ulna dislocated backwards by extension accompanied with forced pro- 
nation ; and in another example, cited by him, forced pronation alone, as 
in wringing wet clothes, was found to have been sufficient. In Her- 
teaux's case the patient had fallen upon her wrist. 

Pathological Anatomy. — Rupture of the synovial membrane (sacci- 
form Ligament), and also rupture of the internal lateral ligament, and of 
the triangular fibro-cartilage, the little head or lower extremity of the 
ulna abandoning its socket in the radius, and being thrown backwards, 
or in -nme cases backwards and outwards, so as to cross obliquely the 
lower end <>f the radius: or it may incline inwards as well as backwards. 

Souse Surgeon Owen, of Bellevue Hospital, called my attention, 
April 4. 1869, to an example of this dislocation in ward 28. The 
patient, Mary Fay, set. 27, having puerperal mania, was confined some 
time in February, in a stra it-jacket, and the accident happened during 
tliis confinement, about six weeks before she came under my notice. 
I found the right ulna displaced backwards so that its articular surfaces 
were completely separated; hut it did not override the radius and with 
moderate pressure ir was n-turned to place. The dislocation and re- 
duction, which had been frequently made by the house staff since the 
accident, caused no pain, but was accompanied with a slight grating 
sensation, 



DISLOCATIONS OF LOWER EXD OF ULNA FORWARDS. 787 

Mrs. Margaret Hogan fell upon her left hand March 3, 1882. She 
applied immediately to one of the city hospitals for relief, but was advised 
that nothing could be done. I saw her four weeks after the accident. 
The radius was not broken. The ulna projected backwards, and she 
was unable to pronate the forearm. It was easily reduced, but would 
not remain in place without support. She was not under my care, and 
I am not informed as to the treatment or its results. 

Mr. Simpson, aet. 50. fell March 9, 1867. striking upon his hand and 
elbow, causing a fracture of the external condyle of the humerus, and a 
dislocation backwards of the lower end of the ulna. The dislocation was 
reduced promptly and easily by Dr. John Dwyer, of this city, and when 
I saw the patient on the following day with Dr. Dwyer, the arm was 
much swollen, but the ulna had remained in place without bandages or 
other means of support. 

Prognosis. — In recent cases the reduction has generally been accom- 
plished without difficulty, and in only three or four instances has the 
bone become spontaneously displaced. 

Loder reduced the ulna after eight weeks, and Rognetta after sixty 
days. In one of the examples to which I have already referred as 
having been seen by myself, the dislocation had existed twenty years, 
the accident having occurred in Ireland when the person was fifteen 
years old. "When I examined the arm, July 21, 1850, the right ulna 
projected backwards and a little outwards, about half an inch. He said 
he had been lame with it for several years, but the motions of the wrist- 
joint were now completely restored, and both pronation and supination 
were perfect. 

Symptoms. — The hand is usually fixed in a position midway between 
supination and pronation. Boyer, however, found the hand in a state of 
extreme pronation. The extremity of the ulna is felt and seen distinctly 
upon the back of the wrist, prominent and movable : and the styloid 
process is no longer in a line with the metacarpal bone of the little 
finger ; the fingers, hand, and forearm are slightly flexed. 

Treatment. — The reduction may be accomplished by holding firmly 
upon the radius and at the same moment pushing the ulna forcibly 
toward its socket ; or by simply supinating the hand strongly. Some 
demand also extension and counter-extension. 

Generally the bone has been found to remain in its place without 
tance, yet in three or four of the examples upon record the constant 
tendency to displacement when the pressure was removed has rendered 
it necessary to employ splints and compresses. 

'< 2. Dislocations of the Lower End of the Ulna Forwards. 

The 'dislocation forwards is said by Malgaigne to be more rare than 
the dislocation backwards. In addition to the nine cases collected by 
him, I have been able to add one reported by Parker, of Liverpool, one 
by R. P. Weir. «»f New York. 1 and one seen by myself. 

While the dislocation backwards te usually caused by violent pronation 

1 Weir, Arch. Clin. Burg., April 15, 1*77, p. 10. 



f88 DISLOCATIONS OF THE LOWER END OF ULNA. 

of the hand, this dislocation is most often occasioned by violent supina- 
tion. The hand is therefore generally found to be supinated forcibly, 
and the projection formed by the end of the bone is seen upon the front 
of the wrist instead of the back. 

By pushing the ulna toward its socket while an attempt is made to 
flex the hand, or by extension, supination, etc., it is made to resume its 
position readily. In the case reported by Parker, how T ever, the reduc- 
tion was effected only while the hand was pronated. 

Parker's case is thus related : 

"John Dalton, aged forty, applied to the hospital, Aug. 9, 1841, under 
the following circumstances : 

" States that he is a carter, and falling down, the shaft of the cart fell 
upon his hand and forearm, in such a way as to supinate them forcibly. 
He complains of pain in the left wrist. The forearm is supinated, and 
cannot be pronated, the attempt causing much suffering. The wrist-joint 
can be flexed or extended without much pain. On looking at the back 
of the wrist, the appearance is characteristic ; the natural prominence 
of the ulna is wanting ; an evident depression exists, as if the lower end 
of the ulna had been dissected out ; it can be traced, however, on a plane 
anterior to the radius, its button-like head being distinctly felt under the 
flexor tendons. Several ineffectual and very painful attempts were made 
to accomplish the reduction, by pushing the head of the ulna into its 
natural situation. This was at last effected by seizing the hand to make 
extension (counter-extension being made at the elbow), then forcibly 
pronating the hand, at the same time pressing backwards the dislocated 
head of the bone with the fingers of the left hand. After persevering 
for a short time, the bone was felt to assume its natural position, the 
wrist acquired its usual appearance, and the ordinary movements of the 
joint could be readily performed. There was no tendency to redisloca- 
tion, and the man was dismissed with directions to keep the bone quiet, 



Fig. 




Dislocation of lower end of ulna forwards. (Case of Wm. Carroll.) 

and to foment it. He attended as an out-patient for two or three days, 
after which, complaining of nothing but a little weakness in the part, a 
bandage was applied, and ordered to be worn for a short time." 1 

1 Parker, Amer. Journ. Med. Sci., April, 1843, p. 470, from Lond. and Edin. 
Month. Journ. Med. Sci , Dec. 1842. 



DISLOCATIONS OF THE CAKPAL BOXES. 789 

The following is the case seen by me : 

Win. Carroll, set. 27, had his left arm caught in machinery and 
" twisted," or rotated violently, causing a simple dislocation of the ulna 
forwards. No attempt was made at reduction. He consulted me Nov. 
14, 1878, several months after the accident occurred, when I found the 
lower end of the ulna projecting on the palmar surface, and inclined 
toward the radius. It could be reduced easily, but would not stay in 
place ; pronation was lost, but all other movements of the arm were pre- 
served. He was a laboring man, and declined to have the necessary 
apparatus applied to secure permanent reduction, since it would prevent 
his immediate return to work. 

Dr. Weir's patient was a woman, ?et. 49, in whom the accident oc- 
curred, Feb. 9, 1877, by a direct force applied to the back of the ulna 
near its lower end. She was seen within a few minutes by Dr. Weir, 
the wrist presenting a singular deformity. It was much narrower than 
the other, and in place of the usual prominence posteriorly, there was 
a deep depression, and the head of the ulna projected slightly in front. 
The hand was semiflexed and nearly supinated. An attempt to reduce 
the dislocation without an anaesthetic failed ; but under the influence of 
an anaesthetic the reduction was accomplished easily, by direct pressure 
made upon the lower end of the ulna. The recovery of the use of the 
hand was speedy and complete. 

I found in the Long Island College Hospital, April, 1869, a girl 13 
years old, who two years before had fallen upon the palm of the right 
hand causing a dislocation of the lower end of the ulna. A doctor applied 
a splint and kept it on four weeks, but when the splint was removed the 
ulna became displaced as at first. When examined by me, the ulna 
became displaced bachvards in the act of supination, and fomvards in 
the act of pronation ; in consequence of which the strength of the w T rist 
was considerably impaired. 



CHAPTER XIII. 

DISLOCATIONS OF THE CAKPAL BONES (AMONG THEMSELVES). 

Bound together on all sides by strong ligaments, and enjoying only a 
very limited degree of motion among themselves, the carpal bones seldom 
become displaced except in gunshot wounds, or in connection with exten- 
sive lacerations and fractures of the neighboring parts. Simple disloca- 
tions, or rather subluxations of these bones, do, however, occasionally 
take place, but, so far as I have been able to ascertain, except in the 
the pisiform, only in one direction, namely, backwards. 

The bones of the carpus, which are said occasionally to have Buffered 
simple backward subluxation, are the semiulnar, cuneiform, and pisiform 
of the first row. and the trapezium, magnum, and unciform of the second 



790 DISLOCATIONS OF THE CARPAL BOXES. 

Magnum. — Richerand, the editor of Boyer's Lectures, says that he 
once met with a subluxation of the os magnum backwards, of which he 
lias given the following account: "Mrs. B., in a labor-pain, seized vio- 
lently the edge of her mattress, and squeezed it forcibly, turning her 
wrist forwards; she instantly heard a slight crack, and felt some pain, 
to which her other Bufferings did not allow her to attend. Fifteen days 
afterwards, happily delivered, and recovered by the care of Professor 
Baudelocque, she showed her left hand to this celebrated accoucheur, 
and expressed her disquietude about the tumor which appeared on it, es- 
pecially when much bent. I was called to visit the lady. I found that 
this hard circumscribed tumor, which disappeared almost totally by ex- 
tending the hand, was formed by the head of the os magnum, luxated 
backwards ; I replaced it entirely by extending the hand and making 
gentle pressure on it. As the affection did not impede the motion of the 
part, as the tumor disappeared on extending the hand, and as it would 
have been but little apparent in any state of the hand had Mrs. B. been 
more in flesh, I advised her not to be uneasy about it, and to apply no 
remedy to it." 1 

Richerand also adds that Boyer and Chopart had each met with the 
same dislocation. 

Bransby Cooper saw the os magnum displaced backwards in a stout, 
muscular young man, by a fall upon the back of the hand when in ex- 
treme flexion. The hand remained slightly bent, and the projection of 
the os magnum was very distinct. Reduction was attempted by extend- 
ing the whole hand, at the same time making pressure upon the displaced 
bone; this not succeeding, extension was made from the middle and 
fore-fingers only, while pressure was kept up on the os magnum, wdien 
suddenly the bone resumed its natural position. On flexing the hand, 
however, the dislocation was immediately reproduced ; and it became 
necessary to apply a compress and splint. For several days after, he 
was in the habit of pushing it out by flexing the hand, in order that the 
young men at Guy's Hospital might see its reduction; which was always 
easily accomplished by simply pushing upon it. 

Magnum and Cuneiform. — Sir Astley says that both the os magnum 
and cuneiform are sometimes thrown a little backwards, from simple 
relaxation of the lignments, producing a great degree of weakness, so as 
to lender the hand useless unless the wrist be supported; and he men- 
tions the case of a young lady in whom the os magnus was thus dis- 
placed, and who was obliged to give up her music in consequence; for 
when -lie wished to ose her hand, she was compelled to wear two short 
>plint>. made fist to the back and forepart of the hand and forearm. 
An'. t her lady, whose hand was weak from a similar cause, wore, for the 
purpose of giving it strength, a strong steel chain bracelet, clasped very 
tightly around the wrist. ' 

Piriform. — South Bays that Gras has described a dislocation of the 
pisiform hone, in the Gazette Med., vol. iii., 1835, 3 and Fergusson says 
he has known an example in which this bone was detached from its lower 

herand, Boyer'a Lectures on Diseases of Bones, Amer. ed., 1805, p. 261. 
A. ( looper, op. cit., j>. 43">. 
3 Note to Chelius, by South, op. cit., p. 234. 



DISLOCATIONS OF THE METACARPAL BOXES. 791 

connections by the action of the flexor carpi ulnaris. 1 Little benefit, he 
thinks, can be expected from any attempts to keep it in place when it is 
dislocated, nor is its displacement of much consequence. In case it were 
dislocated without a rupture of the flexor carpi ulnaris, it would neces- 
sarily be drawn more or less upwards, in the direction of the tendon and 
muscle. In children this bone moves very freely upon the cuneiform, 
and even in adults it is quite movable, and I have seen a surgeon mis- 
take this natural mobility for a partial dislocation. 

Lunar e. — Erichsen thinks he has seen a dislocation of the os lunare 
produced by a fall upon the hand when forcibly flexed. By extension 
and pressure it was easily replaced, but when the hand was flexed the 
dislocation was immediately reproduced. 2 

Notwithstanding that Sir Astley, Miller, and others have taught that 
the cuneiform bone is liable to displacement, and that South has affirmed 
the same of the unciform. I have found no account of an example of 
simple dislocation of single carpal bones except in the cases of the os 
magnum, pisiformis, and lunare, as above mentioned. 

3Iiddle Carpal Articulation. — Maisonneuve has reported an example 
of simple dislocation, without wound of the integuments, at the middle 
carpal articulation. A man had fallen forty feet, and was carried dying 
to F Hotel Dieu. The symptoms were almost precisely those of a dis- 
location of both rows of the carpal bones backwards. The reduction 
was not accomplished during life, but after death a simple effort of trac- 
tion was sufficient to replace the bones. The dissection showed that 
the bones of the second row were almost completely separated from those 
of the first, upon which they were overlapped backwards. A small frag- 
ment of both the scaphoids and cuneiform remained attached to the 
second row, but. with this exception, the separation was complete. 3 

Analogous cases have been reported by Despres 4 and Richmond. 5 



CHAPTER XIV. 

DISLOCATIONS OF THE METACARPAL BOXES (CARPO- 
METACARPAL ARTICULATIONS). 

\ 1. Dislocations of the Metacarpal Bone of the Thumb Backwards. 

MalGAIGNE has seen two complete dislocations of this bone backwards 
upon the trapezium, and he mentions two other cases seen by Michon 
and Bourgnet, respectively. 6 Other surgeons have met with similar 
examples. 

1 Ferg it., p. 190. 

2 Eii Surg., Amer. ed., 1859, p. 259. 

3 Ma op. cit., from Mem. de la Boc. de Chirurg., t. ii. 
* Despres, Bull, de la Soc. de Chi:. 28 avril et 4 mai, 1875. 

5 Richmond, The I i. p. 844. Poinsot, op. cit., p. 969. 

6 Mai_ it., vol. ii. | 



792 



DISLOCATIONS OF THE METACARPAL BONES. 



Fig. 309. 



( '((uses. — They have been found to be caused by falls upon the back 
of the distal extremity of the thumb, forcing the metacarpal bone into a 
position of extreme flexion; and also by blows received upon the end of 
the thumb, forcing it into an opposite direction. In some cases they 
have been caused by blows received directly upon the articulation. 

Symptoms. — The symptoms are sufficiently clear, although the posi- 
tion of the thumb is not always the same. It has been found perfectly 
straight, without any inclination either way, or flexed more or less, with 
the metacarpal bone also inclined inwards toward the palm. The motions 
of the joint are interrupted, and the proximal extremity of the meta- 
carpal bone riding upon the back of the trapezium, projects sensibly in 
this direction, and the trapezium is also felt unusually prominent under 
the thenar eminence. The overlapping varies from a line or two to 
three-quarters of an inch. In the patient mentioned by Bourguet, the head 
of the metacarpal bone almost reached the styloid process of the radius. 
Treatment. — The reduction is to be effected by extension alone, or by 
extension with moderate pressure. In two of the examples reported, 
although the reduction was accomplished very easily, the dislocation was 
reproduced when the extension ceased, and it became necessary to apply 
splints. Malgaigne did not observe, in the case seen by him, any such 
tendency to displacement. 

In the case of Bourguet's patient the reduction w T as never accom- 
plished, although the attempt was made on the second day by a surgeon, 
and repeated after about two months by Bourguet 
himself. 

Fergusson, who has met with several of these dis- 
locations, says that he has seen even a splint and 
roller fail of keeping thase bones in place. 

The following is the only example seen by myself: 
Charles Flannigan, get. 27, caused an incomplete 
backward dislocation of this bone by striking a man 
with his clenched fist. It was never treated by a 
surgeon; and although it always projected a little, 
and the joint was so loose that he could easily push 
it into place, it caused him no inconvenience, and 
after a time the motions became as free as in the 
other thumb. 

About four weeks before he called upon me, and 
twenty-five years after the first accident, he wrenched 
it again. He was then employed as a stage-driver, 
and was fifty-three years old. The dislocation was 
now complete, and the overriding was about one- 
quarter of an inch. The thumb w T as nearly straight, 
the line of its axis being nearly parallel with that 
of the bones of the forearm or only slightly flexed. 
I reduced it easily by extension, and applied a gutta- 
percha Bplint, but 1 have never seen him since, and do not know the 
result. 

Incomplete backward dislocations of the metacarpal bone of the thumb 
seem to be produced by the same causes which cause complete dislocations. 




Case of Peter Golden. 



DISLOCATIONS OF METACARPAL BONE FORWARDS. 793 

The signs of this accident are sometimes obscure, owing to the presence 
of considerable swelling, and they have been often left unreduced. 

In order to the accomplishment of the reduction it will be necessary 
to employ extension, while at the same moment pressure is made directly 
upon the displaced extremity: and to maintain it in place a splint and 
bandage will be required. It is doubtful, however, whether in any case 
the bone can be made to retain so completely its original position as not 
to leave a perceptible deformity. 

Peter Golden, a?t. 16, caused a partial dislocation of this bone back- 
wards by a blow upon the back of the distal end. Two medical men 
whom he consulted on the first and seventh day after the accident failed 
to recognize the displacement. On the thirteenth day he consulted me. 
The projection of the metacarpal bone was now quite manifest, the swell- 
ing having in a great measure disappeared. Having secured the accom- 
panying photograph (Fig. 309), he was placed under the influence of 
ether, and the reduction easily accomplished, and with a carefully padded 
splint of gutta-percha, which included a portion of the arm, it was re- 
tained in place. At the end of six or eight months he was again 
examined by me. The motions of the joint were nearly as free as before, 
but there remained a slight prominence of the metacarpal bone. 

I 2. Dislocations of the Metacarpal Bone of the Thumb Forwards. 

Probably Sir Astley Cooper has reference to an accident of this 
character when he says — speaking of Dislocation of the Head of the 
Metacarpal Bone from the Trapezius — " In the cases which I have seen 
of this accident the metacarpal bone has been thrown inwards, between 
the trapezium and the root of the metacarpal bone supporting the fore- 
finger; it forms a protuberance toward the palm of the hand ; the thumb 
is bent backwards, and cannot be brought toward the little finger." 1 

Sir Astley does not, however, refer to any of the cases which he has 
seen, and Malgaigne says he has not met with such a case, or found one 
recorded. My own experience and observation correspond with that of 
Malgaigne ; although I must confess I have not made it a special purpose 
to look for examples in surgical writings. 

One can never call in question the accuracy of Sir Astley Cooper's 
statements, as to what he professes to have seen, however, and I shall, 
therefore, add what he has said of the mode of reduction. " For the 
facility of reduction, as the flexor muscles are made stronger than the 
extensors, it is best to incline the thumb toward the palm of the hand 
during the time extension is making,- and thus the flexors become relaxed 
and their resistance diminished. The extension must be steadily and for 
a considerable time supported, as no sudden violence will effect the reduc- 
tion. If the bone cannot he reduced by simple extension, it is best to 
leave the case to the degree of recovery which nature will in time pro- 
duce, rather than divide the muscles, or run any risk of injuring the 
nerves and bloodvessels." 

Vidal (d< ys he met with an incomplete forward dislocation, 

1 Sir Astley Cooper's Treatise on Di.-locations, and on Fractures of the Joints, 2d 
London ed., 182 



7!»4 DISLOCATIONS OF THE METACARPAL BONES. 

which he reduced readily, but the patient removed the dressings and the 
dislocation was reproduced, and the bone was not again replaced. 1 

I 3. Dislocations of the Metacarpal Bones of the Fingers. 

Examples of these accidents are so rare that no attempt will be made 
to establish systematically the causes, symptoms, or treatment. Such 
examples as I have found recorded, or as have come under my own 
observation, will be, however, briefly related. 

Dislocations of the Metacarpal Bones of the Fingers Backwards. — 
Roux has recorded one complete dislocation of the second metacarpal 
bone upon the os magnum, caused by an explosion in a mine. It was 
reduced by pressure and extension, but could only be retained in place 
when the hand was flexed. The patient died on the tenth day, and the 
diagnosis was verified by the autopsy. 

The remaining backward dislocations of the metacarpal bones of the 
fingers, and all others that I have found recorded, were incomplete, and 
were generally produced by striking with the clenched fist. I will men- 
tion a few of several cases which have come under my notice. 

In April, 1849, Stephen Peterson, aet. 24, was admitted into the 
Buffalo Hospital of the Sisters of Charity, with a partial dislocation 
backwards of the proximal ends of the metacarpal bones of the index 
and great fingers of the right hand ; produced, as he affirms, by striking 
a man with his clenched fist, about one year previous. He says that he 
called upon a surgeon immediately, but he was unable to keep the bones 
in place. The projection was very manifest at the time of my examina- 
tion, and the hand had never recovered the power of grasping bodies 
firmly. 

During the same year I found in the hospital a precisely similar case, 
in the person of Francis McCoit, aet. 32, a sailor, which had occurred 
four years before, in consequence of a blow given with his fist. The 
same bones were partially displaced backwards, and remained unre- 
duced. This man had also consulted a surgeon soon after the injury 
was received. 

In both of the above examples I instituted a careful examination to 
determine whether it was not the bones of the carpus which were thus 
displaced ; but the result was conclusive as to the nature of the accident, 
and I have obtained casts of both, in order to illustrate partial disloca- 
tions of the metacarpal bones. 

In 1866 I met with a similar case, except that the metacarpal bone of 
the index finger was alone dislocated, at Bellevue Hospital, in a woman 
28 years of age, caused by falling upon her hand with the fingers closed. 
Reduction was easily effected. 

The following example of dislocation of all the metacarpal bones, 
except that of the thumb, is probably without a parallel. Corporal Gar- 
rigan, at the battle of Fredericksburg, Dec. 13, 1862, while holding his 
gun at " ready " was hit by a ball on the back and ulnar side of his left 
baud, the ball traversing the back of the hand between the last row of 

1 Tidal (de Cassia . Traite de Path. Ext., 3d Paris ed., vol. ii. p. 564. 



DISLOCATIONS OF FIRST PHALANX OF THUMB. 795 

carpal bones and the skin, and emerging on the radial side, sending the 
carpal bones forwards and dislocating the metacarpal bones backwards. 
Great swelling ensued, and the nature of the accident was not known for 
some months. When I examined the hand, five years later, the dis- 
placement was very conspicuous ; no fragments of bone had ever escaped. 
The motions of all the fingers, except the index and little fingers, were 
unimpaired. 

Dislocations of the 31etacarpal Bones of the Fingers Fomvards. — 
According to Malgaigne, Bourguet met with a forward dislocation of the 
metacarpal bone of the index finger, caused by a great force applied to 
the back of the hand near the carpus. Reduction was effected by exten- 
sion and pressure. With the aid of splints it was retained in place, and 
a cure effected. 

The following case of forward dislocation of the second metacarpal 
bone at its proximal end has been reported to me by J. Marsh, Asst. 
Surg. U. S. A. : 

On the 1st of April, 1868, Corporal Charles C, set. 25, was struck 
accidentally on the back of his right hand by a hammer weighing seven 
pounds. The hand was at the time firmly clenched, and covered with a 
buckskin glove. The blow was received obliquely. Dr. Marsh saw him 
half an hour after the accident. A marked depression existed on the 
back of the hand, corresponding to the proximal end of the bone, and 
from this point a gradual elevation of the bone could be traced to its 
natural level at the distal end. On the palm of the hand the displace- 
ment was equally manifest. In this position it was fixed, and seemed 
immovable. It was easily and quickly reduced, however, by making 
extension from the fingers, while at the same moment pressure was made 
by the thumb in the palm of the hand. It returned to its place with the 
usual sensation accompanying a reduction of a dislocation, and the de- 
formity at once disappeared ; a ball of tow was now placed in the palm 
of the hand, and secured there by a roller. On the 13th of April he 
returned to duty, but his hand did not acquire its full strength for some 
time longer. 



CHAPTER XY. 

IH -LOCATIONS OF THE FIRST PHALANGES OF THE THUMB 
AND FINGERS (METACARPOPHALANGEAL). 

'<. 1. Dislocations of the First Phalanx of the Thumb Backwards. 

This bone may be dislocated backwards or forwards, but more fre- 
quently the dislocation is backwards. I have met with the backward 
dislocation ten times. 

Causes. — The backward dislocation is occasioned generally by a fall 
or blow upon the distal end and palmar surface of the thumb. 

Symptoms. — J have found the two phalange- in the same axis with 



796 OF FIRST PHALANGES OF THUMB AND FINGERS. 



Fig. 310. 




Dislocation of the first 
phalanx of the thumb 
backwards. 



the metacarpal bone at least twice; that is, neither flexed nor tilted 
backwards ; but in most of the cases the first phalanx inclines backwards 
upon the metacarpal bone, and the second phalanx 
is flexed upon the first, as seen in the illustration. 
Treatment. — The reduction is sometimes, in re- 
cent cases, accomplished with great ease, as the 
following examples will illustrate : 

A servant girl, set. 25, fell down a flight of 
steps Nov. 15, 1850, striking upon the inside of 
her right hand and thumb. When I saw T her, only 
a few minutes afterwards, I found the first pha- 
lanx standing back almost at a right angle w T ith the 
metacarpal bone, and the second phalanx also 
flexed to a right angle with the first. Assisted by 
my pupil, Mr. Boardman, the reduction was effected 
in about twenty seconds, by bending the first pha- 
lanx farther back, and at the same moment press- 
ing the proximal end of this phalanx forwards in 
the direction of the joint. Without employing great force, the reduction 
took place suddenly and with a snap. Very little swelling followed, and 
in three weeks she was able to use her needle without inconvenience. 

Michael Wolfe, set. 35, fell from a height, causing a fracture of his 
left arm, and a dislocation of his right thumb backwards. I saw him 
within two hours after the accident. The thumb w T as much swollen, and 
its position the same as in the case just described. Although Wolfe was 
a strong, muscular man, the reduction w-as accomplished in a few T seconds 
by applying over the last phalanx the Indian toy called a "puzzle," 
and making extension in a straight line, while an assistant made counter- 
extension from the hand and wrist. The use of the joint was soon com- 
pletely restored. 

Examples, however, are constantly occurring, which are only reduced 
after long-continued and painful efforts, or which, indeed, completely 
exhaust the patience and baffle the skill of the most experienced sur- 
geons. 

Mary J. S., set. 23, fell upon her right hand w T ith her fingers and 
thumb extended, in September, 1853, and dislocated this bone back- 
wards. A young surgeon attempted to reduce the dislocation half an 
hour after the accident, by the same manoeuvre adopted by myself 
successfully in the case of the servant girl, only that he made exten- 
sion upon the last phalanx at the same moment. The surgeon believes 
that the bone was reduced, but one week later he found it displaced, 
and, as he believes, reduced it again. The same thing occurred a third 
time- 
Six months after this, the girl consulted me to ascertain what could 
bo done for her relief. The thumb occupied the usual position, and 
admitted of no motion except at the carpo-metacarpal articulation. 

In May, 1*4*. having been called to see G. H., who had attempted 
suicide by cutting his throat, my attention was arrested by the appear- 
ance of his left thumb, and which I found to be occasioned by an 
ancient dislocation of the first phalanx backwards. The accident had 



FIRST PHALANX OF THE THUMB BACKWARDS. 797 

occurred, he afterwards told me, twelve years before, in consequence of 
a fall while wrestling. A very respectable country surgeon was called, 
and made three several attempts to reduce it, but failed. 

The several bones of the thumb occupied their usual positions, that 
is to say, the positions which they usually occupy in this dislocation, 
yet notwithstanding the almost complete anchylosis of the phalangeal 
articulations, and the awkward encroachment of the distal end of the 
metacarpal bone upon the palm, the hand was quite useful. 

In September, 1864, I found in my service at the Charity Hospital 
(Blackwell's Island), New York, an unreduced dislocation of this kind 
in a girl. The surgeons had tried to reduce it, but had failed. 

On the 25th of July, 1857, Catharine Ernst was brought to me, by 
her parents, having a dislocation of the first phalanx of the right hand, 
which had already existed some days, and upon which several unsuc- 
cessful attempts at reduction had been made. The dislocation was 
backwards, but the phalanges, instead of standing at an acute or right 
angle with each other and with the metacarpal bone, as is usually the 
case, were in a straight line with each other and parallel with the meta- 
carpal bone. Whether this phenomenon existed from the first, or was 
due to the efforts already made at reduction, I could not determine, but 
the same thing has been noticed occasionally by other surgeons. The 
first phalanx, moreover, instead of being placed directly behind the 
metacarpal bone, occupied a position upon its back a little to the radial 
side of the centre. 

During quite half an hour I made continued and varied attempts to 
reduce the bone, by extension, by forced dorsal flexion, and by pressing 
the upper end of the first phalanx in the direction of the joint while 
pressure was made against its lower end so as to bring it into dorsal 
flexion, and finally by calling to my aid the "puzzle" and chloroform, 
but all to no purpose. 

One week later I repeated these efforts, and with no better success. 
The parents peremptorily refused to allow me to cut the lateral liga- 
ments, or flexor tendons, so the bone remains unreduced. 

In the following case the relative position of the bones was the same 
as in the preceding case, but the reduction was not difficult : 

Bernard Lawler, aet. 10, w T as admitted to Bellevue Hospital, in Janu- 
ary. 1864, witli a fracture of the femur and other severe injuries. 
The dislocation of the thumb was not noticed until the ninth day. The 
reduction was then easily accomplished, in presence of the class of med- 
ical students, by forced backward flexion. 

Surgical writers have recorded, from time to time, a great many cases 
in which it lias been found difficult or impossible to effect reduction; 
and it is asserted upon the authority of Bromfield, quoted by Hey, that 
the extending force has been increased to such an amount as to tear off 
the last phalanx without having succeeded in reducing the first; but 
while surgeons have united in their testimony as to the exceeding obsti- 
nacy of a large proportion of these dislocations, they are far from being 
agreed as to the source of the difficulty. 

Sir Astley Cooper finds ;i sufficient explanation in the six short and 
powerful muscles which are inserted into the first and last phalanges. 



798 OF FIRST PHALANGES OF THUMB AND FINGERS. 




Fig. 311. and especially in the flexors. 1 Hey be- 

lieves the resistance to be in the lateral 
ligaments, between which the lower end of 
the metacarpal bone escapes and becomes 
imprisoned. Ballingall, Malgaigne, Erich- 
sen, and Vidal (de Cassis) think the me- 
tacarpal bone is locked between the two 
heads of the flexer brevis, or rather be- 
tween the opposing sets of muscles which 
centre in the sesamoid bones, as a button 
is fastened into a button-hole. Pailloux, 
Lawrie, Michel, Leva, Blechy, Roser, and 
Hueter affirm that the anterior ligament, 
ciove-hitch. including a portion of the capsule, being- 

torn from one of its attachments, falls be- 
tween the joint surfaces and interposes an effectual obstacle to reduction. 
A case of compound dislocation is recorded, in which Esmarch saw the 
capsule in this position, and button-holed upon the distal end of the 
metacarpal bone.' 2 Dupuytren ascribes the difficulty to the altered rela- 
tions of the lateral ligaments, which are naturally parallel to the axis of 
the metacarpal bone, but which are now placed at a right angle ; to the 
spasm of the muscles, and to the shortness of the member, in consequence 
of which the force of extension has to be applied very near to the seat 
of the dislocation. Lisfranc found in an ancient dislocation the tendon 
of the long flexor so displaced inwards and entangled behind the extrem- 
ity of the bone as to prevent reduction. Esmarch met with a similar 
case, in which he opened the joint and replaced the tendon, with a satis- 
factory result. 3 Deville discovered in an autopsy a similar displacement 
of this tendon outwards. Wadsworth has made the same observation. 4 



Fig. 312. 




Sir Astley Cooper's method of reducing dislocations of the thumb, with pulleys. 

The modes of reduction practised and recommended by these different 
surgeons are as diversified and irreconcilable as their views of the mech- 
anism and pathological anatomy of the accident. 

Sir Astley Cooper recommends that extension shall be made by bend- 
ing the thumb toward the palm of the hand, to relax the flexor muscles 

1 Lawrie, of Glasgow, Bays that Sir Astley, in a conversation with him, declared 
that the " sesamoid hones" were the sources of the difficulty. See Am. Journ. Med. 
Sci , vol. wii. j) 230, with observations and experiments by Lawrie. 

2 Esmarch, Berliner Klinische Wochensch., 1876, No. 44. 

3 Ibid. 

* Wadsworth, Am. Med. Times, Feb. 13, 1864, p. 77. 



FIRST PHALANX OF THE THUMB BACKWARDS. 799 

as much as possible, and then, by fastening a clove-hitch upon the first 
phalanx, previously covered with a piece of soft leather, the extension 
is to be continued, only inclining the thumb a little inwards toward the 
palm of the hand. If these means fail after having been continued a 
considerable length of time, he advises that a weight shall be suspended 
to the thumb, passing over a pulley. Finally, in the event of the failure 
of this method also, Sir Astley thought that no further attempt should be 
made, and especially that no operation for the division of these parts is 
justifiable. 

Lizars and Pirrie adopt the views of Sir Astley with little or no quali- 
fication. 

Charles Bell proposed flexing the joint, employing at the same time 
pressure ; and in obstinate cases he advised subcutaneous section of the 
lateral ligaments with a small knife, a method which has since been prac- 
tised successfully by Liston, Reinhardt, Gibson, of Philadelphia, Parker, 
of New York, myself, and others. Syme and Lizars justify the practice 
in certain cases. In one case which has come under my notice, after 
failing to effect reduction by the usual methods, I succeeded promptly 
after cutting one lateral ligament ; and in the second case I only suc- 
ceeded after cutting both lateral ligaments. 

Roser. from his experiments upon the cadaver, concludes that the dis- 
located phalanx must first be bent forcibly backwards, or into the posi- 
tion termed by some writers dorsal flexion, so as to throw the head of the 
phalanx forwards upon the articulating surface of the metacarpal bone. 
Parker, of New York, in his notes to the American edition of Samuel 
Cooper's work, recommends the same procedure. 

Vidal (de Cassis) recommends also that the extension should be made 
first, backwards, so as to increase the displacement of the first phalanx 
in this direction, and to throw forwards its articular surface in the direc- 
tion of the articular surface of the metacarpal bone. 

Hueter believes that if this method fails, when combined with some 
rotation and lateral motion, no other is likely to succeed, and he then 
advises resection. He has, however, himself in all cases been able to effect 
reduction, but the difficulty has been to maintain it, owing to the inter- 
position of the capsule: and in such cases he has reduced the dislocation 
and then applied a plaster bandage, grasping the splint and thumb with 
his hand until the plaster was hard, and leaving it undisturbed for four- 
teen days, at the end of which time he has found that the bones would 
remain in place without the aid of the splint. He believes that the inter- 
posed ligament has been in the meanwhile absorbed. To me it seems 
quite certain that with the capsule thus interposed, permanent anchylosis 
must be the final result, even though it might be possible to retain the dis- 
located surfaces in apposition, and that resection would be preferable. 

This method, namely, dorsal flexion, as the first and most essential 
part of the manoeuvre, seems to have met with more general approval 
than any other, and the following observations, made by the late Reuben 
D. Mussey, of Cincinnati, illustrate the general practice among Ameri- 
can surgeons at this day: 

M I tilt the dislocated phalanx up until it stands upon its articulating 
end, place both forefingers so as to hold it in that position, and at the 



800 OF FIRST PHALANGES OF THUMB AND FINGERS. 

same time press against the distal extremity of the metacarpal bone, 
make firm pressure with the thumbs against the base of the dislocated 
phalanx, and slide it into its place, which can generally be accomplished 
with ease. 

"More than twenty-five years ago, the chairman of this committee, 
from attention to the mechanism of the metacarpo-phalangeal joint of the 
thumb, convinced himself that the principal impediment to the reduction 
of the first phalanx from backward displacement is the short flexor of 
the thumb, between the two portions of which (lying close together where 
they are fastened to the sesamoid bones) the head of the metacarpal 
bone has been thrust, the contracted part or neck of this bone lying 
firmly grasped by them. Fifteen years ago, a case occurred of this dis- 
location which he could not reduce in the ordinary way. A subcutane- 
ous division of one of the heads of this muscle was made with an ins 
knife, and the reduction was accomplished with the greatest ease. 

"Last year another case occurred, in which we failed of reduction by 
Dr. Crosby's method, which we believe to be the best, and the subcu- 
taneous division of both heads of the muscle was made, and the reduc- 
tion instantly effected. The punctures were covered with collodion, and 
the thumb supported by a splint. As the patient was intemperate, entire 
abstinence from liquor and the adoption of a light diet were enjoined. 
Neither pain nor inflammation followed, and a month afterwards the joint 
had free motion. After the intemperate and irregular habits were re- 
sumed, the joint in a few weeks was found anchylosed. In these cases, 
the knife, in the subcutaneous operation, was carried down to the meta- 
carpal bone, so far behind its head as to preclude the possibility of mis- 
taking the lateral ligaments for the muscles. The ligaments are very 
short, and inserted close to the articular surfaces, and are probably, one 
or both, ruptured in this dislocation." 1 

Dr. J. P. Batchelder, of New York, in a paper read before the New 
York Medical Association in 1856, says : " The surgeon should take 
the metacarpal portion of the dislocated thumb between the thumb and 
finger of one hand, and flex or force it as far as may be into the palm 
of the hand, for the purpose of relaxing the muscles connected with the 
proximal end of the phalanx, particularly the flexor brevis pollicis. He 
should then apply the end of the thumb of his hand against the displaced 
extremity of the dislocated phalanx, for the purpose of forcing it down- 
wards, and at the same time grasp the displaced thumb with his other 
hand, and move it forcibly backwards and forwards, as in strongly forced 
Ilex ion and extension, the pressure against the upper extremity of the 
first phalanx being kept up. In this way the dislocated bone may be 
made to descend, so as to be almost or quite on a line with the articu- 
lating surface of the metacarpal bone, when the thumb may be forcibly 
flexed, and, if it be not reduced, as forcibly extended, and brought 
backwards to a right angle with the metacarpal bone ; when, if the down- 
ward pressure, with the thumb placed as before, directed for that purpose, 
lias been continued (which thumb, by maintaining its position, acts as a 
fulcrum, as well as by its pressure), the bone will slip into its place, and 

1 Musaey, Trans. Amer. Med. Assoc, vol. iii. p. 357, 1850. 



FIRST PHALANX OF THE THUMB BACKWARDS. 801 

the reduction be effected in less time than has been spent in describing 
the process.'" 1 

Six successive cases of treatment by this method are mentioned in the 
American Journal of Medical Sciences for April, 1858; one by Rick- 
ard. one by Morgan, two by Cutter, and two by Crosby. I have also 
once succeeded by the same method. 

By those who have regarded extension as an important element in the 
reduction, various instruments have been devised for the purpose of ob- 
taining a secure hold upon the dislocated member. Sir Astley Cooper, 
as we have already seen, recommended the sailor's clove-hitch ; 2 Lawrie 
advises that the thumb shall be thrust into the open handle of a large 
door-key; 3 Charriere and Luer, of Paris, have each invented forceps, so 
constructed with the fenestra and straps, that when the blades are closed 
the member is held very firmly in its grasp. Richard J. Levis, of Phila- 
delphia, recommends "a thin strip of hard wood, about ten inches in 
length, and one inch, or rather more, in width. One end of the piece is 
perforated with six or eight holes. The opposite end is partly cut away, 
forming a projecting pin, and leaving a shoulder on each side of it. 
Toward tins end of the strip, a sort of handle shape is given to it, so as 

Fig. 313. 




Levis's instrument for reduction of dislocations of fingers or the thumb. 

to insure a secure grasp to the operator. Two pieces of strong tape or 
other material, about one yard in length, are prepared. One of these 
is passed through the holes at the ends of the strip, leaving a loop on 
one side. The other tape is passed through another pair of holes, ac- 
cording as it may be a thumb or a finger to which it is to be applied, or 
varied to suit the length of the finger, leaving a similar loop. If a dis- 
located thumb is to be acted on, the second tape should be passed through 
the boles nearest the first. The ends of each separate tape are then tied 
1 1 er. 
" To apply this apparatus, the finger is passed through the loops. The 
loop nearest the first joint is then tightened by drawing on the tape, which 
is then brought along the strip to the opposite end, across one of the 
shoulders, and secured by winding it firmly around the projecting pin. 
The other tape is tightened in a like manner, crossing the other shoulder, 
and winding around the pin in an opposite direction, when, for security, 
da of the tapes are finally tied together." 4 

" .v York Journ Med., May, 1866, )>. 340. 
2 Op. cit.. ]». 661 : also Boston Med. and Surg. Journ., Oct. 1, 18-">7. 

Lawrie, Amer. Journ. Med. S<--i . . vol. wii. p. 229. 
4 Levis, Amer. Journ. Med. Sci . Jan. 1867, p. 62. 
51 



S0'2 OF FIRST PHALANGES OF THUMB AND FING.ERS. 

This apparatus enables the operator to apply both extension and flexion 
or Leverage in any direction. The proximal end of the phalanx may be 
lifted, or even rotated so as to allow one side of the bone to approach the 
socket before the other. 

Malgaigne describes an apparatus invented by Kirchoff, which is very 
similar to, yet not quite so complete as this of Levis. 

Fig. 314. 




Levis's instrument applied to the first finger. 

In the April number of the Buffalo Medical Journal, for 1847, 1 have 
described an instrument, or rather a toy, in my possession, which I sug- 
gested might be useful for the purpose of making extension upon dislo- 
cated fingers ; and which, as will be seen by a reference to one of the 
cases already reported in this chapter, I have since applied successfully. 
It is made by the Indians, and may always be obtained during the water- 
ing season, at the Indian toy-shops at Niagara Falls. The Indians call 
it a "puzzle," and know no other use for it than to fasten it upon the 
thumb or finger of some victim, and then pull him about until he begs to 
be released. 



Fig. 315. 




Indian "puzzle," employed for the reduction of dislocations in small joints. 

The "puzzle" is an elongated cone of about sixteen or eighteen inches 
in length, made of ash splittings, and braided; the open end of the cone 
being about three- fourths of an inch in diameter, and the opposite end 
terminating in a braided cord. When applied to the finger, it is slipped 
on lightly, forming a cap to the extremity, and to half the length of the 
finger, but on traction being made from the opposite end, it fastens itself 
to the limb with a most uncompromising grasp. If constructed of ap- 
propriate size and of suitable materials, it becomes the more securely 
fastened in proportion as the extension is increased; yet applying itself 
equally to all the surfaces, it inflicts the least possible pain and injury 
upon the limb. When we wish to remove it, we have only to cease pull- 
ing, and it drops off spontaneously. 

Dr. Holmes says that the same instrument is made by the Indians of 
Maine, and that several years ago Dr. Davis, of Portland, brought one 
to Boston, and showed it to the Society for Medical Improvement, sug- 



FIRST PHALANX OF THE THUMB FORWARDS. 803 

gesting that it might be used for the same purpose which I have recom- 
mended. 1 

Finally, in some compound dislocations it would be better not to attempt 
the reduction of the dislocation until resection has been practised. 
Samuel Cooper relates a case in which the reduction was followed by in- 
flammation and death within a week after the accident, and Norris, of 
Philadelphia, mentions an instance which came under his observation, 
where violent inflammation and tetanus followed the reduction. 2 Roux, 
Evans. Wardrop, Gooch, Sir Astley Cooper, and many other surgeons, 
have practised resection successfully in these accidents, and have added 
their testimony in favor of this mode of procedure. 

I 2. Dislocations of the First Phalanx of the Thumb Forwards. 

Up to the present moment, I have met with but two examples of this 
dislocation, while, as has been already stated, the backward dislocation 
has been seen by me ten times. 

Horace Kneeland, of Rochester, N. Y., aet. 24, dislocated the first 
phalanx of the right thumb forwards, by striking a man with his clenched 
fist : the force of the blow being received upon the back of the second 
joint of the thumb. The dislocation had existed three days when he 
called upon me, and in the meanwhile several attempts had been made 
to reduce the bone by simple extension. The first phalanx was in front 
of the metacarpal bone, and in the same plane ; but the last phalanx was 
slightly inclined backwards. The hand was already swollen and quite 
painful. 

Seizing the dislocated thumb in the palm of my right hand, with my 
fingers resting upon the back of the patient's hand I forced the two 
phalanges into flexion by firm and steady pressure continued for a few 
seconds, when suddenly the bones resumed their places, and all deformity 
disappeared. 

Intense inflammation resulted, followed, after a few days, by suppu- 
ration under the palmar fascia ; and in the end the thumb was almost 
completely anchylosed. 3 

On the 24th of April, 1855, J. M. Booth, of Buffalo, set. 19, called 
at my office, having a dislocation forwards of the first phalanx, occasioned, 
about half an hour before, by being thrown from a horse. The last two 
phalanges were neither flexed nor extended, but straight, and parallel 
with the metacarpal bone. 

By the same manoeuvre adopted in the preceding case, but with only 
very moderate force, the dislocation was promptly reduced. 

Causes. — The usual causes of this accident are falls or blows upon the 
thumb while it is flexed; Lombard has seen it produced by a fall upon 
the palmar surface of the thumb. 

Symptoms, — The symptoms which characterize it are, in general, such 
as we have seen in the two examples which have just have been given. 
The metacarpal bone projects posteriorly, and the first phalanx produces 

1 Trans. Am. Med. Assoc, vol. i. p. '2<'>1 . 

2 Xorris, Amer. Journ. Bled. 8ci., vol. xxxi. p. 10. 
5 Trans. >". Y. State Med. Soc„ 1800, p. 73. 



804 OF FIRST PHALANGES OF THUMB AND FINGERS. 

a corresponding projection toward the palm; the two phalanges are ex- 
tended upon eaeli other, and parallel with the metacarpal bones. Nek- 
ton saw a ease in which the first phalanx was flexed about 45° ; and in 
Beveral examples it has been observed to be slightly rotated inwards. 

Treatment — In the few examples of this accident which have been 
reported, the reduction was easily accomplished; or, at least I may say 
that the difficulties in the way of reduction were not so great as they are 
usually found to be in dislocations backwards. Malgaigne has been able 
to collect but four undoubted examples, all of which were reduced ; 
Lenoir was able to effect the reduction by moderate measures, after the 
bone had been dislocated thirty-eight days. Ward succeeded by simple 
extension. 1 

Lombard, after the trial of other plans, finally succeeded by reversing 
the phalanx. Employing, as I have before termed it, "dorsal flexion," 
with extension and lateral motion; but in all, or nearly all the other 
examples, the reduction has been effected by flexing the thumb forcibly 
toward the palm ; the reverse of the method which we have seen pre- 
ferred, especially by American surgeons, in dislocations backwards. My 
<»wn experience also authorizes me to recommend this plan. 

^ 3. Dislocations of the First Phalanx of the Fingers. 

The index and little fingers, owing to their exposed situation, are most 
liable to these dislocations. I have met with three examples of traumatic 
dislocations of these joints, one of which was a forward and two were 
backward dislocations, and all had occurred in the index finger. 

Fig. 316. 




Backward dislocation of first phalanx. Reduction by extension. 

James Neshitt, of Buffalo, set. 11, dislocated the index finger of the 
righl hand, backwards, by a fall down a flight of stairs. On the same 
day, Feb. 11, 1851, he called upon me, and I found the finger neither 
flexed no)- extended, but straight and immovable. The projections occa- 
sion <■< I by the ends of the two bones were very marked, and such as to 
render an error in the diagnosis impossible. Reduction was accom- 
plished with great ease, by reversing the finger and employing moderate 
extension, while at the same time the proximal extremity of the first 
phalanx was pushed toward the distal end of the metacarpal bone. In 
short, the process was the same as that which I have recommended in 
dislocations of the thumb backwards. 

1 Waid, New York Med. Times, Sept. 8, 1860. 



PHALANGES OF THE THUMB AND FINGERS. 805 

In the second case, presented in a woman 35 years of age, at Charity 
Hospital, April 16, 1868, the dislocation was caused by her husband 
having pulled the finger violently backwards. The metacarpal bone was 
thrust through the skin on the palm of the hand. Four weeks had now 
elapsed, and the wound had healed. A few days before, the house sur- 
geon had placed her under the influence of ether and had attempted 
reduction, but had failed, and she refused to allow me to repeat the 
attempt. 

In the example of dislocation forwards, occasioned by a blow from a 
hard ball, received upon the end of the finger, the first phalanx was in a 
position of extreme extension, and the second moderately flexed. Reduc- 
tion was effected with great ease by extension in a straight line. But if 
the surgeon were to experience difficulty in the reduction, it would no 
doubt be advisable to resort to the method of extreme flexion. 

In one instance, I have seen nearly all the fingers of the left hand, 
and the thumb of the right, dislocated backwards by the contraction of 
the cicatrix after a severe burn. 



CHAPTER XVI. 

DISLOCATIONS OF THE SECOND AND THIRD PHALANGES OF 
THE THUMB AND FINGERS (PHALANGEAL). 

Notwithstanding slight differences in the form of the articulations 
between the thumb and fingers, and in the size and situation of the bones 
which compose the phalanges of the fingers, I am disposed, contrary to 
the practice of some other writers upon this subject, to consider all the 
dislocations to which these several joints are liable, under one section. 
Nor, indeed, after the attention which I have given to the dislocations 
at the metacarpophalangeal articulations, do I find much to add in 
relation to these accidents: since in almost every point of view in which 
they may be considered, they have so much in common. 

The last phalanx of the thumb is, of all the phalanges, most liable to 
dislocation, and this generally takes place backwards. Very frequently, 
also, it is accompanied with such a laceration as to render it compound. 
The dislocated phalanx is usually reversed in the backward dislocation, 
and straight, or nearly so, in the forward dislocation. 

In most cases reduction may be accomplished easily by forced dorsal 
flexion in the case of the backward dislocation, and by forced palmar 
flexion in the case of the forward dislocation. 

In the winter of 1848, a young man was brought into my clinic, who 
had met with a forward subluxation of* this phalanx about one month 
before. He had fallen upon the end of his thumb, and as the accident 
was followed by a good deal of inflammation and swelling, li<3 did not 
notice the displacement until some time afterwards. The proximal end 
of the last phalanx projected two or three lines toward the palm ; the 



80fi 



PHALANGES OF THE THUMB AND FINGERS. 



finger was Btraight, and this joint anchylosed. I did not think the 
chance of restoring and maintaining the bone in position sufficient to 
warrant any interference, and he was dismissed with an assurance that 
after a few months it would occasion him no great inconvenience. 

On the 2d of* March, 1851, Thomas Burton, aged about twenty-two 
years, by a fall dislocated the second phalanx of the middle finger of the 
right hand, backwards. The force of the concussion was received upon 
the extremity of the finger. Nine hours after the accident I found the 
bones unreduced ; the finger nearly straight, or with only slight flexion 

Fig. 317. 




Dislocation of the second phalanx backwards. 

of the second phalanx upon the first ; the third phalanx forcibly straight- 
ened upon the second ; all the joints rigid ; finger very painful and some- 
what swollen. 

By moderate extension alone, applied for a few seconds, the reduction 
was accomplished. 

James Cooper, set. 23, came to me on Sunday morning, the 14th of 
Dec. 1851, to obtain counsel in relation to his finger which had been 
dislocated the day before, but which he had himself reduced by simple 
extension made in a straight line. His own account of it was, that he 
fell upon a slippery sidewalk, striking upon the end of his ring finger 

Fig. 318. 




Dislocation of the second phalanx forwards. 

in Buch a way that it seemed to double under him. On examination, he 
found the second bone dislocated inwards, or to the ulnar side, com- 
pletely, the end of the first phalanx forming abroad projection upon the 
opposite side ; the last two phalanges fell over tow r ard the middle finger, 
but they were neither flexed nor extended. Seizing upon the end of the 
finger with his right hand and pulling forcibly, he promptly reduced the 
dislocation himself. 

The bones were now completely in place, but the joints were swollen, 
tender, and quite stiff". 

In Sept. 1851, by the politeness of Dr. Briggs, the attending surgeon, 
I was permitted to see. in the hospital of the New r York State Prison, at 



PHALANGES OF THE THUMB AND FINGERS. 807 

Auburn, a forward dislocation of the second phalanx of the little finger 
of the left hand, unreduced. The man was at the date of my examina- 
tion forty-one years old, and the dislocation had existed eighteen years ; 
having been occasioned by a fall. A surgeon in Greene Co., N. Y., had 
attempted to reduce it soon after the dislocation occurred, but had failed. 
The joint was nearly anchylosed, yet the finger was quite as useful for 
all ordinary purposes as before. 

Dislocation of the last phalanx is frequently occasioned in the game 
of base-ball, by the ball being received upon the extremity of the finger. 

A young man who was studying medicine, and a private pupil of mine, 
in attempting to catch a very hard ball, received it upon the extremity 
of the middle finger of the left hand, dislocating the last phalanx forwards. 
Twenty minutes after the accident, I found the distal extremity of the 
second phalanx projecting backwards through the skin, the tendon of the 
extensor muscle being torn completely off from its point of attachment to 
the last phalanx. The last phalanx was in a position of slight dorsal 
flexion, or extreme extension. 

Seizing upon the extremity of the finger, I attempted to reduce the 
dislocation by direct traction, aided by pressure upon the exposed end 
of the second phalanx, but I was unable to succeed until I brought the 
last phalanx into a position of palmar flexion. 

A slight disposition to redislocation was manifested, and a gutta-percha 
splint was therefore applied ; and, to prevent inflammation, the young 
man was directed to keep it moistened with cool water lotions. Only a 
moderate amount of inflammation followed, and in a few weeks the cure 
was complete. 

Such accidents, attended with laceration of the integuments, may occa- 
sionally demand amputation, or at least resection of the projecting bone; 
but I think Mr. Miller is scarcely right when he says that compound 
dislocations of the fingers almost always are of such severity as to de- 
mand amputation. I have myself met with three other cases which were 
reduced, and did well. 

In one case of simple dislocation of the last phalanx of the thumb 
backwards I have been obliged to resort to section of the lateral liga- 
ments before accomplishing the reduction. This was in the person of a 
woman admitted to Bellevue Hospital in February, 1864. The accident 
had happened seven days before, by falling and striking upon the end of 
the thumb. The position of the last phalanx was extended, that is, in a 
line with the axis of the first phalanx. She said, however, that it was 
at first "bent straight back," but that a man took hold of it and pulled 
it out. Having placed her under the influence of ether, I attempted 
reduction by forced backward flexion, but failed. I then cut the lateral 
ligaments by subcutaneous incision, and the reduction was accomplished 
with great ease. 



808 DISLOCATIONS OF THE THIGH. 



CHAPTER XVII. 

DISLOCATIONS OF THE THIGH (COXO-FEMORAL). 

The femur is especially liable to dislocation in four directions, namely, 
upwards and backwards upon the dorsum ilii, upwards and backwards 
into the ischiatic notch, downwards and forwards into the foramen thy- 
roideum, and upwards and forwards upon the pubes. 

Dislocations are occasionally met with which cannot be arranged 
properly under either of these divisions ; indeed, it is scarcely necessary 
to say that the head of the bone may be thrown in almost every direction 
from its socket, upwards, downwards, inwards, and outwards, or in either 
of the diagonals between these lines; and that while in a vast majority 
of cases it will assume one of the positions first named, it may in a few 
exceptional examples fall short of, or much exceed, the limits assigned 
in this division. Thus, I shall have occasion hereafter to mention ex- 
amples of dislocation directly upwards, in which the head of the bone 
will be found resting upon the fossa between the upper margin of the 
acetabulum and the anterior inferior spinous process of the ilium ; or still 
higher, between the anterior superior and the anterior inferior spinous 
processes ; or a little to the one side or to the other of these points. Ex- 
amples will be shown of dislocations directly downwards, in which the 
head of the femur will rest upon the notch between the lower margin of 
the acetabulum and the tuber ischii ; or still lower, and actually below 
the tuberosity ; or downwards and backwards below the spine of the 
ischium, into the lower or lesser sacro-sciatic notch. The head may be 
thrust across the foramen thyroicleum, and be only arrested in the peri- 
neum upon the ramus, or even beyond the ramus of the ischium and 
pubes ; it may lodge upon the anterior surface of the body of the pubes, 
as well as upon its superior edge ; it may rest against the posterior mar- 
gin of the acetabulum, instead of rising upon the dorsum ; or it may 
only mount upon its margin, in either of the directions named. 

In regard to frequency, the four principal dislocations occur in the 
order in which I have mentioned them; thus, of 104 dislocations of 
the hip which I have taken the pains to collate, excluding the anomalous 
or extraordinary dislocations, and which my intelligent pupil, Mr. Frank 
Hodge, has carefully analyzed, 5b were upon the dorsum ilii, 28 into 
the great ischiatic notch, 13 upon the foramen thyroideum, and 8 upon 
the pubes. Chelius and Samuel Cooper have, however, reversed the 
order of the last two varieties, arranging dislocations upon the pubes, in 
the order of frequency, before dislocations into the foramen thyroideum. 

Coxo-femoral dislocations may occur at any period of life ; a case of 
thyroid dislocation is reported in the Lancet for May 16, 1868, which 
occurred in a child six months old. One example is mentioned in the 
Gazette 3Iedicale, of a recent dislocation upon the dorsum ilii, in a child 



DISLOCATIONS OF THE THIGH. 809 

eighteen months old. 1 Dr. N. Fanning, of Catskill, N. Y., informs me 
in a letter dated June 25, 1867, that he has reduced a dislocation upon 
the dorsum ilii, on the tenth day, in a little girl eighteen months old. 
Mr. Kirby has reported, in the Dublin Medical Press for October 26, 
1842, a case of recent dislocation in the same direction, in a child of 
three years. 2 and Dr. Buchanan has seen another, at the same age, in a 
little girl : the dislocation being into the ischiatic notch. 3 Mr. Image 
communicated to the Suffolk branch of the Provincial Medical and Sur- 
gical Association the case of a boy, three and a half years old, with a 
dislocation upon the dorsum ilii. It had existed twelve days when he 
was admitted to the Suffolk Hospital in May, 1847. Mr. Image, in re- 
porting this case to the Society, remarked that he had been induced to 
lay it before them " in consequence of a charge having been urged against 
a neighboring surgeon, of pretending to reduce a dislocation of the femur 
in the dorsum ilii, in a child only four years old, that child being a 
pauper, and chargeable to the parish. It was agreed and proved by 
authorities that no such case was recorded, and therefore had not oc- 
curred, and that seven years old was the earliest period at which this 
accident had taken place." 4 

J. M. Litten, of Austin, Texas, reports a case of dislocation upon the 
dorsum ilii in a girl four years old, which he reduced by manipulation. 5 
Dr. V. P. Gibney, of New York, has reported a case in a boy of four 
years, which he reduced after six weeks. 6 Dr. Alexander Thompson, of 
Onondaga, N. Y., has reported another case in an Indian boy four years 
old. The dislocation was upon the dorsum ilii, and it was reduced 
promptly, under ether, by Drs. Thompson and Dee. 7 Dr. Sands C. 
Mason, of Leonardsville, N. Y., has reduced a dorsal dislocation in a 
girl of the same age. 8 In the January number for 1847 of the American 
Journal of Medical Sciences is reported a forward dislocation in a boy 
aged five years, and a dislocation into the ischiatic notch in a girl of the 
same age. Dr. A. B. Cook, of Louisville, Ky., has reduced a dorsal 
dislocation in a boy six years old. 9 

Loewell 10 reduced, in a child four years old, an iliac dislocation without 
difficulty, which had existed twenty-six days. Laurence 11 reduced a dis- 
location in the foramen ovale easily, which was six weeks old, without an 
anaesthetic. 

Dr. J. 0. Warren, of Boston, met with an incomplete dislocation 
toward the foramen thyroideum in a child six years old. which, having 
been displaced eight or ten weeks, he was unable to reduce. 12 Sir Astley 

1 New York Journ. Med., Nov. 1850, p. 416. 

Lmer. Journ. Med. Sci., vol. xxxi. p. 207, Jan. 1843. 
■ London Med.-Chir. Rev., Dec. 1828, p. 251. 

New York Journ. Med., Sept. 1848, p. 281. 
8 I hid., March, 1852, p. 259. 
t; A.mer. Journ. Med. Sci., Oct. 1870. 
7 Bosp Gaz., Nov. 15, 1879. 

■1. Gaz., April 21, 1888. 
'' Richmond and Louisville Med. Journ., May, 1878. 

10 Loewell, Rec Mem. de M<v). Mi].. Janv. Pev. 1*7';. 

11 Laurence, Cent, fur Chir., 1878, No. LI, p. 188. 
Boston Med. and Surg. Journ., vol. xxiv. p. 220. 



810 DISLOCATIONS OF THE THIGH. 

Cooper mentions a ease in a girl seven years old. 1 I have myself met 
with two dislocations upon the dorsum ilii, which occurred at ten years, 
and one into the foramen thyroideum. 2 Norris reports a case at eleven 
years, 8 and Gibson at twelve. 4 

On the other hand, Dr. P. J. Kline, of Portsmouth, Ohio, has reported 
to me a case of dislocation of the femur in a woman aged seventy-three, 
and which thirteen years later he found unreduced; and Grauthier has 
seen a dislocation of the hip in a woman eighty-six years of age. 5 The 
large majority, however, occur between the fifteenth and forty-fifth years 
of life. From an analysis of eighty-four cases, I have obtained the 
following results : 

Under 15 rears 15 cases. 

15 to 30 " 32 " 

30 to 45 " 29 " 

45 to 60 " 7 " 

66 to 85 " 1 case. 

Dislocations of the hip are much more frequent in men than in 
women ; owing, probably, to the greater exposure of the former to the 
accidents from which these dislocations usually result, and possibly, also, 
in some measure, to certain peculiarities in the form and structure of the 
neck of the femur in the male. Of one hundred and fifteen cases col- 
lected by me, one hundred and four were in males and eleven in females. 
Dr. J. K. Rodgers, of New York, mentioned, however, at a meeting of 
the New York Kappa Lambda Society, that he had seen, and reduced 
four dislocations of the femur upon the dorsum ilii in females, and that 
a fifth case had recently come to his knowledge in the New York City 
Hospital. 6 

Gibson mentions an example of dislocation of both thighs at the same 
moment, 7 and Schinzinger has reported a case of double dislocation, in 
which the right femur was found in the ischiatic notch, and the left above 
the pubes. 8 

Sigonowitz, Andreini, Crawford, Bigelow, Steiner, and Pollard have 
each reported examples of double dislocations of the hip. 9 

§ 1. Dislocations Upwards and Backwards on the Dorsum Ilii. 

St/n. — - : Upwards on the dorsum ilii ;" Sir A. Cooper, Miller, Pirrie. " Upwards 
and outwards;" Boyer, Dupuvtren. i; Upwards and backwards upon the back of 
the hip-bone;" Chelius. " Iliac;" G-erdy, Yidal (de Cassis), Malgaigne. 

Causes. — Generally they are occasioned by some violence which forces 
the thigh into a state of extreme adduction, or of adduction united with 

1 A. Cooper, on Disloc., Amer. ed., p. 83, Case 27. 

2 Buffalo Mod. Journ.. vol. viii. p. 6. Trans. New York State Med. Soc, 1855. 
M v Report "n Disloc. 

A.mer. Journ. Med. Sci., Feb. 1839, p. 296. 
Kbson'a Surg., vol. i. p. 389. 

ithier, Malgaigne, op. cit., p. 805. 
' .1. K. Rodgere, New York Journ. Med.. July, 1839, vol. i., first ser., p. 220. 
7 Gibson's Surg., vol. i. p. 385, sixth ed. 
' The [nternational Surgical Kecord, vol. i. No. 2 ; from Wiener Med. Presse, 1880, 

: Centralb. f. Chir.^1880. Xo. 11. 
9 Poinsot. op. cit., p. 1007. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 811 

rotation inwards : and especially when at the same moment the head of 
the femur is driven upwards and backwards. Thus, a dislocation upon 
the dorsum may result from a fall from a height, when the force of the 
concussion is received upon the outside of the knee : the thigh being 
thus converted into a lever of the first kind, whose long arm is outside 
of the margin of the acetabulum ; or the dislocation may be occasioned 
by a fall upon the foot or knee, while the limb is adducted, by which the 
head of the femur will be at the same moment driven upwards and out- 
wards from the socket. The accident is equally liable to result from the 
fall of a heavy weight, such as a mass of earth, upon the back of the 
pelvis when the body is much bent forwards. 

The following case presents an extraordinary example of this form of 
dislocation produced by a force acting upon the thigh as a lever of the 
first kind : 

B., of Rochester, N. Y„ set. 10, fell, in Feb. 1841, from the top of 
the high bank just below the Genesee Falls, at Rochester, a distance of 
about one hundred feet. Before he reached the bottom of the precipice, 
he struck upon an oblique plane of ice, from which he slid gradually 
down upon the surface of the river, which was then completely frozen 
over. He did not lose his consciousness in the descent, nor after his 
arrest upon the river, but began immediately to call for assistance. He 
remembers very well that when he struck the glacier, the concussion was 
received upon the right side of the right knee, and a mark of contusion 
at this point confirmed his statement. Dr. Ellwood, of Rochester, as- 
sisted by myself, reduced the dislocation within one hour after its occur- 
rence. We employed pulleys, but the reduction was accomplished easily 
in about two minutes, and without the application of much force ; the 
bone resuming its place with an audible snap. His recovery was rapid 
and complete. 1 

Pathological Anatomy. — The capsule is lacerated more or less exten- 
sively, but especially in its posterior half; the round ligament is rup- 
tured ; some of the small external rotator muscles are generally stretched 
or torn completely asunder, the gluteus maximus, medius, and minimus 
are pushed upwards and folded upon each other, the head of the femur 
re-ting upon or within the fibres of the deep muscles; the triceps ad- 
ductor is put upon the stretch. 

Surgeons have not been agreed as to the cause of the great difficulty 
which has sometimes been experienced in the reduction of this and of all 
other forms of coxo-femoral dislocations. While some have ascribed it 
alone to the resistance of the muscles, others have with equal confidence 
ascribed the opposition to an entanglement of the head and neck of the 
bone in the rent capsule, or to the resistance offered by certain untorn 
ligaments ; and still others believe that the impediment ought to be looked 
for sometimes in the muscles and sometimes in the untorn portion of the 
capsule. 

.Sir Astley Cooper thought that the capsular ligament was generally 
too much torn to offer any impediment to reduction, and he refers to 
some dissections in confirmation of this opinion. Nathan Smith affirmed 
that the chief obstacle to reduction by extension was to ho found in the 

1 Trans. New York State Med. Boc., 1866, }>. 76. My report on Dislocations. 



812 



DISLOCATIONS OF THE THIGH. 



Fig. 319. 



resistance offered by the glutei muscles, which, although at first relaxed, 
would soon become tense under the stimulus of the extension, and which, 
in order that the bone might resume its position, must actually be 
stretched considerably beyond their normal length. 1 W. W. Reid declares 
that the sole resistance is at first in the abductors and rotators, but that 
finally the psoas magnus, iliacus interims, and triceps adductor become 
tense when the pulleys are employed. 2 
Chassaignac recognizes no other impedi- 
ment to reduction than the contractions of 
the muscles. 3 Parmentier, 4 in a dissec- 
tion, found the head imprisoned between 
the pyramidalis and obturator interims ; 
while Servier 5 found the head and neck 
strangled between the pyramidalis and the 
glutgeus medius. 

Dr. Fenner, of New Orleans, gives the 
particulars of a dissection of the hip of a 
man admitted into the Charity Hospital, 
who died from injuries received by the 
bursting of a steamboat boiler. His con- 
dition being considered hopeless, no at- 
tempt was made to reduce the dislocation. 
The limb was shortened one inch and a 
half, and the toes turned inwards. Exten- 
sive ecchymosis existed. On raising the 
gluteus maximus and medius, the naked 
head of the femur was found lying on the 
dorsum ilii with the ligamentum teres 
hanging to it, but partially torn off. Por- 
tions of the obturator externus piriformis, 
and gemelli, were ruptured and lacerated. The capsule was torn through 
one-half of its extent. 

Dr. Fenner now proceeded to cut away the muscles, and when all the 
external muscles about the joint had been removed the thigh could not 
be brought down ; the iliacus internus and psoas magnus were then sev- 
ered, which permitted it to descend a little, but the head could not be 
replaced ; the triceps adductor was then divided without effect. The 
ilio-femoral ligament was found tensely stretched. All the muscles 
between the pelvis and the thigh were then severed, and still it was im- 
possible to reduce the dislocation ; the head of the femur could not be 
forced back through the rent in the capsule from which it had escaped ; 
and it was not until the opening was enlarged from one-half to three- 
quarters of an inch, that the reduction was accomplished. 

Dr. Fenner infers that the capsule possesses sufficient elasticity to 
allow the small head of the femur to pass out through a lacerated open- 

1 Surgical Memoirs, by N. R. Smith, 1831. 

2 Buffalo Med. Journ., 1851. Trans N. Y. State Med. Soc, 1852. 

3 London Med. Times and Gazette, Dec. 1865, p. 661. 

4 Parmentier, Bull. Soc. Anat., Paris, 1850, p. 177. 

5 Servier, Bull. Soc. Chir. Paris. 1863, p. 485. 




Dislocation upon the dorsum ilii. 



UPWARDS AXD BACKWARDS OX THE DORSUM ILII. 813 



ing. which might at once contract, so as to offer considerable resistance 
to its return, and that occasionally this is the true explanation of the 
difficulty in reduction. 1 

Moses Gunn, Professor of Surgery in Rush Medical College, Chicago, 
who has devoted much time to the study of this subject, and to experi- 
ments upon the cadaver, says : ** In dislocations of the hip and shoulder, 
the untorn portion of the capsular ligament, by binding down the head 
of the dislocated bone, prevents its ready return over the edge of the 
cavity to its place in the socket ; but its return can be easily effected by 
putting the limb in such a posi- 
tion as will effectually approxi- Fig. 820. 
mate the two points of attachment 
of that portion of the ligament 
which remains untorn." 2 

Dr. Moore, of Rochester, who 
has often repeated the same ex- 
periments upon the cadaver, de- 
clares, also, that in attempting 
to reduce the femur by extension 
alone he has constantly observed 
that the untorn portion of the 
capsule offered the main resist- 
ance, and that reduction could 
not be accomplished until this 
was more completely broken 
up. 3 

Busch. of Bonn, has arrived 
at similar conclusions '} as also 
Professors Roser, "Weber, and 
Gelle. 

Professor Yon Pitha declares 
that upon a knowledge of the 
die-femoral ligament is based 
the correct understanding of the 
various forms of hip-joint dis- 
locations. 5 

A very elaborate exposition of 
the relations of the ilio-femoral 
ligament to these accidents has 

been furnished by Dr. Henry J. Bigelow, the Professor of Surgery 
in Harvard University. The following is a brief summary of his 
opinions. 

1 New York Journ. Med., Sept. 1848, p. 268, from New Orleans Med. and Surg. 
Journ., July. 1848. 

- Gunn, Paper read before the Detroit Medical Society, by Moses Gunn, Ml)., 
A.M., LL.D., Professor of Surgery, Bush Med. College, Peninsular Journal, Sept. 

3 New York Journ. Med., Jan. 1866. 

i Year-Book of Med. and Surg, for 1864. Sydenham Soc. Publications : from 
Archive- of Clinical Surgery, vol. iv., part i., Berlin, 1863. fPoinsot.j 
Vod Pitha's and Billroth 's Surgery, vol. iv., lS'i-j. fPoinsot.j 




Ilio-femoral ligament. (Bigelow.) 



814 DISLOCATIONS OF THE THIGH. 

The ilio-femoral ligament, called by Dr. Bigelow the Y ligament (Ber- 
t in's ligament), the internal obturator muscle, and that portion of the 
capsule of the joint which is immediately subjacent, are alone required 
to explain, and are chiefly responsible for, the phenomena of the four 
regular dislocations. The regular dislocations are those in which com- 
plete disruption of the ilio-femoral ligament has not taken place. 

The irregular dislocations are those in which the ilio-femoral ligament 
has suffered complete disruption. 

In reducing either of the regular dislocations the limb must be flexed, 
in order to relax the ilio-femoral ligament ; but if other portions of the 
capsule are not sufficiently torn to admit the return of the head within 
its socket, it must be torn by circumduction of the limb. After flexion, 
and perhaps circumduction, the reduction may be completed by rotation, 
or by extension of the thigh at right angles with the anterior surface of 
the body. 

Fig. 321. 




Dislocation upon the dorsum ilii. (Bigelow.) 

The dorsal dislocation owes its inversion to the external fasciculus of 
the ilio-femoral ligament. 

In the ischiatic dislocation, "dorsal below the tendon" (Bigelow), the 
head is arrested, in extension, by the tendon of the obturator and the 
subjacent capsule. 

The flexion and eversion of the limb in the thyroid dislocation are due 
to the ilio-femoral ligament. 

In the pubic dislocation the ascent of the limb is finally arrested by 
the ilio-femoral ligament. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 



815 



Prof. Gimn, who is not fully in accord with Dr. Bigelow's conclusions, 
says : 

" This portion of the capsule, the Y ligament, is, manifestly, much the 
strongest, and is probably rarely torn asunder in any of the four classical 
dislocations, except the thyroid, in which it is, probably always, com- 
pletely ruptured, as I shall have occasion to demonstrate in the course 
of the present paper. Its entire want of influence in the dorsal variety 
of dislocation I shall also be able to show by exhibition of a dissection of 
the parts 

" I desire to direct attention to another structure which plays an assist- 
ing role in holding the head of the femur down outside the ridge of the 
acetabulum in the dorsal dislocation. If, in an intact state of the muscles 
and the external portion of the fascia lata, the capsular and round liga- 
ments be completely divided, and the head of the femur be dislocated 



Fig. 322. 



Fig. 323. 





Anterior view, showing tense condition 
of anterior and inferior portion of cap- 
sule, and the loose state of the ilio-feinoral 
portion in the dorsal dislocation. (Gunn.) 



Posterior view of same specimen, show- 
ing the tense state of the anterior and 
inferior untorn portion of capsular liga- 
ment. (Gunn.) 



upon the dorsum of the ilium, it will be found that the characteristic 
deformity of direction in the limb will be wanting, i. e., the limb will be 
parallel with its fellow, on a line with the trunk lacking the inversion 
and adduction, but will be shortened the usual extent. If now the limb 
be placed in the position characteristic of dorsal dislocation in the living 
subject, and the reduction be attempted by the old method of extension 
and counter-extension, it will bo found that the head is still held down 
firmly in its hooked position outside of the ridge of the acetabulum. It 
is thus hold by the fascia lain, which in this position of the limb describes 



816 



DISLOCATIONS OF THE THIGH. 



Fig 32-4. 



the outermost curve, and consequently is put upon the stretch and holds 
the whole trochanteric end of the bone pressed firmly inwards. 

"These figures," continues Prof. Gunn, "as is the case in all my 
illustrations, are made from a dissection of the parts, which dissection I 
also herewith exhibit. It is seen that the anterior and inferior portion 
of the ligamentous capsule is untorn, tense, and holds the dislocated 
head firmly hooked outside the dorsal portion of the rim of the ace- 
tabulum, while that portion of the capsule between the anterior inferior 
spinous process of the ilium and the anterior intertrochanteric line of 

the femur, which is reinforced and 
strengthened by the ilio- femoral 
fibres, is quite loose, owing to the 
approximation of these two points, 
in the shortened, adducted, and in- 
ternally rotated state of the limb 
which characterizes this form of 
dislocation. Thus, this ilio-femoral 
portion of the capsule, in the dorsal 
dislocation, is entirely without in- 
fluence, either in determining the 
deformity or in opposing our efforts 
at reduction. It is entirely to the 
anterior and inferior portion of the 
capsule that these influences are 
due." 

Symptoms. — Sir Astley Cooper 
affirmed that the limb was some- 
times found shortened in this dislo- 
cation to the extent of three inches. 
Liston, B. Cooper, Gibson, and 
others, repeat the affirmation. Che- 
lius places the extreme of shorten- 
ing at two and a half inches ; Mil- 
ler, at two inches ; while Malgaigne 
declares that he has never seen the 
limb shortened more than half an 
inch, and that in some cases it is 
not shortened at all, and the very 
opposite opinions entertained by 
other surgeons he attributes to 
errors in the measurement. I am 
certain, however, that Malgaigne 
has fallen into some error, and that, 
while the average shortening is about one inch or one inch and a half, it 
does occasionally reach three inches. 

The thigh is rotated inwards, adducted, and slightly flexed upon the 
pelvis. The great toe of the dislocated limb, when the patient stands 
erect (and in this position the examination ought, if possible, to be made), 
rests upon the instep of the foot of the sound limb, and the knee touches 
the opposite thigh near the upper margin of the patella. It must not 




Dislocation upon the dorsum ilii. 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 817 

be supposed, however, that the position of the limb is in all cases pre- 
cisely such as I have described. Indeed the degree of rotation, adduc- 
tion, flexion, etc., will vary according as the head of the femur is more 
or less displaced, the capsule, including the ligaments, more or less torn ; 
or as it may be torn in its upper or lower margins, as the muscles may 
be actually rent asunder or only put upon the stretch, and perhaps also 
according to the amount of injury and consequent relaxation which they 
may have sustained from the shock. The thigh can be easily flexed ; 
adduction is more difficult, and abduction is almost impossible, except to 
a very limited extent ; the body of the patient is a little bent forwards, 
the roundness of the hip is lost in consequence of the relaxation of the 
glutei muscles ; the trochanter major is depressed, and approaches the 
anterior superior spinous process of the ilium ; and if the patient is not 
fat. and swelling has not already taken place, the head of the femur may 
be felt in its new position rotating under the hand when the limb is 
turned inwards or outwards, but especially may it be felt when, by flex- 
ing or extending the limb, the head is made to move downwards and 
upwards, upon the dorsum ilii. 

As I have already said, this examination ought to be made, if possi- 
ble, in the erect posture; after which, it will be well to place the patient 
alternately upon his back, upon his sound side, and upon his belly, until 
the diagnosis is rendered complete. 

The differential diagnosis between dislocation upon the dorsum ilii and 
a fracture of the neck of the femur may be briefly stated as follows. 

In fracture, we may expect to find crepitus ; the limb is in most cases 
mobile ; the toes arc generally turned out ; the limb is shortened moder- 
ately or not at all ; the patient is sometimes able to walk for a short dis- 
tance; fractures of the neck of the femur generally occur in advanced 
life. 

In dislocation, crepitus is not often present, and only when a fracture 
coexists ; the limb is immobile, or nearly so ; the toes are turned in ; the 
limb is shortened more; the patient is unable to bear the weight of his 
body upon his foot for one moment. Skey, however, says he has seen a 
patient with a recent dislocation, who walked one-quarter of a mile, to 
the hospital. I do not think that any other similar case is upon record. 
Dislocations of the femur generally occur in middle life. 

I have been frequently told by persons who have called upon me with 
children suffering from hip-disease, that they had been informed the hip 
was out, and they expected me to reduce it. In two or three instances 
they have blamed their surgeons very much, because they had not de- 
tected the accident at the time of its occurrence. Norris, of Philadel- 
phia, mentions an extraordinary example of this kind, as having been 
presented at the Pennsylvania Hospital, and which ought to serve as a 
sufficient warning to prevent similar mistakes in future. A lad twelve 
years old, was brought to the hospital from a neighboring State, who a 
short time previous had been suddenly attacked with lameness in his right 
limb, and which, by his friends, was attributed to some injury received in 
play. Two physicians, who had been called to see the boy, pronounced 
him to be laboring under dislocation of the hip, and had made two strong 
efforts with the pulleys, to reduce it; but after causing great suffering, 

62 



sis 



DISLOCATIONS OF THE THIGH. 



Pig. 325. 



they gave up all hopes of ever replacing the bone, and sent him to Phila- 
delphia. The symptoms were plainly those of hip-joint disease in its 
early stage. The attitude was that assumed by those laboring under 
this affection; the leg seemed lengthened, but a careful measurement 
showed that it was of the same length with the other; the buttock was 
flattened, and the motions of the joint were tolerably free but painful. 1 

If the supposed dislocation occurs in a child, or in a person under ten 
year- of age, we ought to take especial pains to ascertain that it is not a 
separation of the epiphysis, of which accident I have mentioned some 
examples when speaking of fractures of the 
neck of the femur. 

Examples have occasionally been reported 
of "everted dorsal dislocations," in which 
most of the usual signs of a dorsal dislocation 
are present, except that the limb is everted, 
and sometimes slightly abducted. Bigelow 
attributes this condition to a rupture of the 
outer fibres- of the ilio-femoral ligament, and 
he affirms that under these circumstances the 
limb may be found inverted, but it is also 
easily everted; the foot may be slightly 
everted, it may lie flat upon the bed, or it 
may even point backwards. 

The treatment of the everted dorsal dislo- 
cation consists in reducing it first to an ordi- 
nary dorsal dislocation by flexion and rotation 
inwards, aided by adduction, if necessary. 

Prognosis. — Boyer says the limb remains 
always weaker than the other, the round liga- 
ment never uniting completely ; and that in- 
flammation of the cartilages and synovial 
glands may ensue, ending in caries of the 
joint. Such results have, indeed, been oc- 
sionally met with, nor are examples wanting 
in which more rapid inflammation, resulting 
in the formation of acute abscesses, has fol- 
lowed, but these are only rare accidents. .In 
the large majority of cases the patients recover speedily, and in course of 
a few weeks, or months at most, the limb seems to be as sound and as 
useful as before. 

In one case reported from my clinic at Bellevue, the patient, aged 33, 

after I had reduced a recent dorsal dislocation by manipulation, walked 

OH the fourth day; and on the seventh day he ascended five flights of 

- to the amphitheatre, walking without any halt. He declared, also, 

that he felt do soreness or lameness about the hip. 2 

Examples of non-reduction, however, from an error of diagnosis, or, 
what ifl more pertinent to our present purpose, from a failure to accom- 




Everted dorsal dislocation. 
(Bigelow.) 



Aiucr. Journ. Med. Sei., vol. xxv. p. 280. 
tion of a Dorsal Dislocation of the Femur. The Med. Record, Dec. 3, 
1876, p. 780. 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 819 

plish the reduction where the attempt has been made, are numerous. 
Fortunately. Mr. Chelius, the author of a most excellent System of 
Surge i'>i. to which I have already had frequent occasion to refer, has 
sufficient reputation, the world over, to enable him to bear a portion of 
these failures, without injury to himself or to the profession which he 
so eminently adorns. I shall therefore make no apology for reporting 
the following unsuccessful attempt to reduce a dislocation of the hip in 
which Mr. Chelius himself was the operator : 

On the 11th of June, 1851, John Mauren, a German, set. 19, called 
at my office and related as follows: fc< When ten years old, I fell from a 
tree, a height of six feet, and dislocated my left hip. I was then living 
twelve miles from Heidelberg, and I was immediately taken there, but 
I did not see Mr. Chelius until the next morning. He took me to the 
University, and, before the medical class, attempted to reduce it, but he 
could not. During several weeks following, he tried six times, using 
pulleys, etc., but he could never succeed." 

On examination, I found the limb shortened two inches, the head of 
the femur lying upon the dorsum ilii ; the knee was turned in, but the 
toes were inclined a little outwards. He was able to walk rapidly, of 
course with a manifest halt, yet without pain or discomfort. 

Treatment. — Regarding dislocations of the femur upon the dorsum 
ilii as the type of all the coxo-femoral dislocations, the remarks which 
I shall make under this section may be considered applicable, with only 
certain qualifications, to all the others. 

I shall arrange the various methods of reduction which have been 
employed by surgeons under two principal heads, namely, manipulation 
and extension. It is not possible, however, to classify rigidly the dif- 
ferent procedures, so as to bring them under these two simple divisions, 
without some violence : since neither manipulation nor extension has 
usually been employed alone, but almost always some degree of exten- 
sion lias been recommended in connection with the manipulation; if not 
in the first instance, at least in the event of the failure of manipulation 
alone ; while, on the other hand, extension is seldom if ever practised 
without manipulation. I intend, then, to imply by these designations 
respectively, that either manipulation or extension has constituted the 
prevailing feature in the treatment. 

Reduction by manipulation dates from the earliest records of our 
science. Says Hippocrates: "In some the thigh is reduced with no 
preparation, with slight extension directed by the hands, and with slight 
movement : and in some the reduction is effected by bending the limb 
at the joint and making rotation." 1 

Richard Wiseman, who wrote in 1676, speaks as follows: "If the 
thigh-hone be luxated inwards, and the patient young and of a tender 
itution, it may be reduced by the hand of the chirurgeon, viz., he 
must lay one hand on the thigh, ami the other on the patient's leg, and 
having somewhat extended it toward the sound leg. he must suddenly 
force the knee up toward the belly, and press back the head of the 
femur into its acetabulum, and it will snap in. For there is no need 

1 Works of Hippocrates, Syd. ed., vol. ii. p. 043. 



820 DISLOCATIONS OF THE THIGH. 

of so great extension in this kind of luxation; for the most considerable 
muscles being upon the stretch, the bowing of the knee as aforesaid re- 
duceth it; yet in rough bodies it may require stronger extension." ] 

Richard Boulton repeated, in 1713, almost the same instructions, 
affirming that this plan was applicable especially to dislocations inwards, 
in the case of "young and tender children." 2 

In 1742, Daniel Turner declared that he had reduced three disloca- 
tions of the hip, one of which was a backward dislocation, by a method 
combining extension with manipulation, but alone " by the strength of the 
arm or without any other instrument." Extension and counter-extension 
being made by assistants, and "as soon as the surgeon perceives the bone 
moving out," says Turner, "let him take his opportunity, giving orders 
to the extenders below suddenly to lift up the patient's thigh toward his 
belly, pressing with his hands either to the right or left, as the situation 
of the same requires, and therewith force back its head toward the aceta- 
bulum, whereunto it will, flipping over the tip of the cartilage, snap 
sometimes with a loud noise." 3 

Thomas Anderson, surgeon, of Leith, in Scotland, was called, in Sept. 
1772, to see a man who had dislocated his left femur into the foramen 
thyroideum. When he arrived four other surgeons were present, and 
prepared to use the pulleys, which they did in his presence several times, 
but to no purpose. After examining the limb carefully, "I was con- 
vinced," says Mr. Anderson, "that attempting the reduction in the 
common method, w T ith the thigh extended, was improper, as the muscles 
were all put on the stretch, the action of which is, perhaps, sufficient to 
overbalance any extension we can apply. But by bringing the thigh to 
near a right angle with the trunk, by which the muscles would be greatly 
relaxed, I imagined that the reduction might more readily take place, 
and w r ith much less extension. 

"When I made this examination, he was lying on a table on his back. 
I raised the thigh to about a right angle with the trunk, and, with my 
right hand at the ham, laid hold of the thigh, and made what extension 
I could. From this trial I found I could dislodge the head of the bone. 
At the same time that I did this, with my left hand at the head and 
inside of the thigh, I pressed it toward the acetabulum, while my right 
gave the femur a little circular turn, so as to bring the rotula inwards 
to its natural situation ; and on the second attempt it went in with a 
snap observable to the gentlemen standing around, but more so to the 
poor man, who instantly cried out he was well and free from pain. His 
knees could then be brought together ; the legs were of the same length, 
and the foot in its natural situation. The knees were kept together for 
some time, with a roller, to confine the motion of the thigh; and in three 
weeks he was at his work, without the least stiffness in the joint." 

Subsequently Mr. Anderson reduced, by a similar method, a disloca- 

1 Eight Chirurgical Treatises. By Richard Wiseman, Serjeant-Chirurgeon to King 
Charles II. London, 1676. Book vii. chap. viii. 

2 A System of Rational and Practical Surgery. By Richard Boulton. London, 
1713 p. 846. 

3 The Art of Surgery. By Daniel Turner. London, 1742, vol. ii. p. 339. 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 821 

tion upon the dorsum ilii in a child eight years old, and which had been 
out nineteen days. 1 

Says Pouteau, in a memoir on dislocations of the thigh upwards and 
outwards : "We observe, then, first, that the thigh ought to be flexed to 
a right angle with the body during the extension and counter-extension ; 
second, that we ought to rotate the thigh from within outwards, when 
the extension appears to be sufficient ; third, that this position puts into 
relaxation, as much as possible, the triceps and gluteal muscles, wdiich 
oppose the chief resistance to the extension, thus saving the patient from 
excessive pain ; fourth, that the flexion of the thigh places the head of 
the bone in the best position for a return to the cotyloid cavity during 
extension ; fifth, that feeble extensionj suffices for reduction, because all 
the muscles of the thigh are relaxed." 2 

On the Tth of January, 1811, Dr. Philip Syng Physick, of Phila- 
delphia, reduced an outward dislocation of the hip, after extension had 
failed, by flexing the thigh to a right angle w T ith the body, and then 
giving to the limb an " outward circular sweep." 3 

So early as 1815, and perhaps much earlier, Nathan Smith, Professor 
of Surgery in the New Haven Medical College, taught that the only 
correct mode of reducing a dislocation upon the ilium was to flex the leg 
upon the thigh, the thigh upon the pelvis, and then to carry the 
limb diagonally to the opposite side, whence it was to be brought out- 
wards and downwards ; 4 and in 1824, Dr. Smith, being under oath, 
affirmed as follows : " I do not think that the mechanical powers, such 
as the wheel and axle, or the pulleys, are necessary to reduce a dislo- 
cated hip, or any other dislocation." He further adds that he once 
reduced a dislocation upon the dorsum ilii after he had pulled in every 
direction but the right, " by carrying the knee toward the patient's 
face." 5 Subsequently the son of Dr. Smith, Nathan R. Smith, the 
present distinguished teacher of surgery in the Medical College at Balti- 
more, gave a more full account of his father's method, illustrating his 
views of the pathology of these dislocations, and the mechanism of their 
reduction, by several drawings. It must be noticed, however, that Dr. 
Nathan Smith left no written explanation of his views and practice, except 
that which is to be found in the affidavit already quoted, and that the 
account published by his son is from memory, and it is given as follows: 
"The patient, being prepared for the operation by whatever means may 
be deemed necessary, may be placed in an attitude convenient for the 
operation, with the body securely fixed, by placing him in the horizontal 
posture, on a narrow table covered with blankets, and on the sound side. 
To the table his body should be firmly fixed, and this can be conveniently 
done by folding a sheet several times, lengthways — then applying the 
middle of the broad band thus made to the inner and upper part of the 

1 Anderson, Bfedical.Commentaries, Edinburgh, 1776, vol. ii. pp. 201-4. 

2 Vidal (di om CEuvres posthumea de Pouteau, Paris, 1788. 

3 Physick, D . Surg., 1813, vol. i. p. 242. Mem of Nathan Smith, 1831, p. 
17-j Phelps's paper in Trans. New York State Sled. 8oc., 1856, p. 169. 

* Trans. N. \\. State lied. Boc., 1854, p. 56. 
Report of the Trial of an Action for Malpractice. Lowe] v. Faxon and Hawks, 
Machias, Maine. 1824; also Buffalo lied. Journ., vol. xiii. p. 515. 



MSLOCATIONS OF THE THIGH. 

Bound thigb — carrying its extremities under the table, crossing them 
beneath it, and then carrying them obliquely up and crossing them firmly 
over the trunk, above the injured hip. The ends may then be secured 
beneath the table. To supporl the trunk the more firmly, a pillow may 
hi' placed on each side of it upon the table, and be included in the band- 
Should the operator design to employ any degree of extension, a 
counter-extending hand may be placed in the perineum, and carried up 
to the extremity of the table, be fixed to some more firm body, or held 
by the hands of assistants. 

•• The <»perat<»r, now standing on the side to which the patient's back 
presents, grasps the knee of the dislocated member with his right hand 
(if the left femur be dislocated — vice versa^ if the right), and the ankle 
with the left. The first effort which he makes is to flex the leg upon 
the thigh, in order to make the leg a lever with which he may operate 
on the thigh-bone. The next movement is a gentle rotation of the thigh 
<»ut wards, l>v inclining the foot toward the ground, and rotating the knee 
outward-. Next the thigh is to be slightly abducted by pressing the 
knee directly outwards. Lastly, the surgeon freely flexes the thigh 
upon tlic pelvis by thrusting the knee upwards toward the face of the 
patient, and <if the scone moment the abduction is to be increased. 

•• Professor N. Smith regarded the free flexion of the thigh upon the 
pelvis as a very important part of the compound movement. He believed 
that it threw the head of the bone downwards, behind the acetabulum, 
where the margin of the cup is less prominent, and over which, therefore, 
the abductor muscles would drag it with less difficulty into its place. 

•■ The operator may slightly vary these movements, as he increases 
them, so a- to give some degree of rocking motion to the head of the os 
femoris, which will thereby be disengaged with the more facility from 
it- confined situation among the muscles." 1 

Dr. Luke Howe, of Boston, who was a pupil of Nathan Smith's, gives 
the following account of the method practised by him successfully, about 
the year 1820, and which method, he says, was recommended by his 
preceptor: " The patient was permitted to lie on his back on the bed 
where I found him, the knee of the luxated limb turned in and over the 
other. I raised the knee in the direction it inclined to take, which was 
toward the breasl of the opposite side, till the descent of the head of the 
bone gave an inclination of the knee outwards, when I made use of the 
leg, being :it :i right angle with the thigh, as a lever to rotate the latter 
and turn the head of it inwards. It then readily returned to its socket, 
with ;m audible snap. During this operation, the two assistants who 
had been placed to make the lateral extension and counter-extension, if 
ultimately required, were directed to draw moderately at their towels. 
I! much of the success of the operation is to be imputed to their ex- 
tension, and the rotation of tin." thigh by the leg, I am unable to deter- 
mine : hut :i^ Dr. Smith succeeded without the aid of either, and as the 
head of tin- femur seemed to descend by an easy and natural process, I 
am inclined to believe that all thai is necessary, in such cases, is to ele- 

: and Surgical Memoirs, by Nathan Smith, late Prof, of Sur^erv, etc., in 
i Nathan R. Smith, Professor of Surgery in Univ. of Mary- 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 



823 



vate the knee, when the ilium, the muscles attached to it, and perhaps 
the ligament, become the natural fulcrum, over which the thigh, as a 
lever, acts to bring the head down and inwards into the socket." 1 

Kluge, in 1825, combined moderate extension with manipulation, by 
flexing both the leg and thigh, while at the same moment the thigh was 
abducted and the knee rotated inwards. 2 Wathman, in 1826, directed 
that in this dislocation the limb should be seized by the knee and ankle 

Fig. 326. 




Nathan Smith's method of reduction by manipulation. (From Smith's " Memoirs.") 

and slowly lifted forwards until it came to a right angle witli the long 
axis of the body; when, if the outward "self-twisting of the thigh" 
occurs, "which cannot be prevented by fast holding," the movement of 
the head of the bone is declared, and it will only remain for the surgeon 
to let down the thigh gradually upon the bed so that the two limbs will 
come side by side, and the reduction will be accomplished. 3 

Rust recommended also, in 1826, a similar plan, combining moderate 
extension by the hands, with flexion and abduction of the thigh. 4 

Colombot, whose opinions date from 1830, suggested that the patient 
should lay himself forwards upon a bed or tabic no higher than his 
hip-, with the sound leg and foot resting upon the (lorn-, and that then 
tie- Burgeons seizing the foot with one hand, so as to flex the leg. should, 
with the other hand, exercise a moderate degree of extension, and ;it the 
time move the limb to the right or to the left, backwards and for- 



1 How*--. Boston Med. and Surg. Journ., vol. wii. p. 249, 

2 Chelius'a Surir., by South, Amor, ed., vol. ii. ]>. 241. 
* Ibid., p. 24 South. 



May, 



L840. 

< I lml.. 






B24 LIS LOCATIONS OF THE THIGH. 

wards, in order to disengage the head of the femur; and, finally, that 
lu- Bhould communicate to the thigh a sudden movement of circular rota- 
tion, either from within outwards, or from without inwards, as the sur- 
i may choose. 1 

Collin states that, in 1833, lie had reduced four dislocations of the 
hip by a method very similar to this recommended by Colombot. 2 

Dr. William Lngalls, of Chelsea. Mass., reduced a compound disloca- 
tion of the femur, in which the head of the bone rested upon the pubes, 
after an unsuccessful attempt had been made to reduce it by extension. 
"An assistant, taking the ankle of the dislocated limb in his right hand, 
and placing his left in the ham, bent the leg at right angles upon the 
thigh, and the thigh upon the pelvis, then lifting with a power little 
more than sullieient to elevate the whole limb, he carried it to its greatest 
Btate of abduction, at the same time rotating the femur inwards, while 
Dr. Ingalls passed his thumb through the w r ound, and, pressing upon the 
head of the femur, directed it toward the acetabulum At this moment 
he directed the limb to be forced toward its fellow, by which the reduc- 
tion was effected with the greatest possible ease and elegance." 3 

Similar methods of reduction, with only such slight variations as 
scarcely deserve a special notice, have been suggested and practised 
from time to time by Palletta, in 1818 ; 4 Despres, in 1835 ; 5 Vial, in 
1841 ; 6 Fischer, Mahr, and Clark, in 1849. 7 

In 1851 Dr. W. W. Reid, of Rochester, N. Y., published an account 
of the method practised by himself successfully in three cases of dislo- 
cation upon the dorsum ilii, the first of which dated from the year 1844. 
\\\< method, as applied to a dislocation upon the dorsum ilii, consists in 
"flexing the leg upon the thigh, carrying the thigh over the sound one, 
upwards over the pelvis as high as the umbilicus, and then abducting 
ami rotating it." 8 

Dr. Markoe, of New York, adopts the same procedure, except that 
when the limb has been sufficiently flexed and abducted, he directs that 
the limh shall he gradually brought down, and he affirms that it is during 
this last manoeuvre that he has usually found the bone resume its place 
in the socket. 9 

Bigelow, of Boston, declares, as has already been stated, that in all 
the regular dislocations, that is to say, in all those dislocations in which 
the ilio-femoral ligament is not torn, the thigh must be first flexed, in 
order to relax this ligament, and then reduction may be effected by ex- 
tension directly forwards, the thigh being at a right angle with the body, 
<»r by rotation. In some cases, where there is probably only a button- 
hole alii in the capsule, free circumduction maybe required in order that 
the capsule may be torn more freely. 

]\\< method of reducing the dislocation upon the dorsum ilii, is to flex 
the thigh upon the abdomen, ahduct and then rotate outwards ; or, to 

M - "!'• cit., vol. ii. ]>. 825. 2 i D ja M p . 823. 

asby Cooper's eel. of Sir Astlcy's English eel., 1842, and Amer. ed., 

* ( | note by South ■"> Malii-ai^ne. 6 Ibid. 

: Dublii Dec. 8, 1851. New York Journ. Med., March, 1852. 

Journ., vol. vii. pp. 139-143, Aug. 1851. 
1 M Journ. Med.. January, 18.55. 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 825 

flex, then adduct and rotate a little inwards, to disengage the Lead of the 
bone from behind the socket, then abduct and pull directly upwards. 
When necessary, circumduction is practised to lacerate the capsule more 
completely. 

Says Prof. Gunn, of Chicago : "I think, therefore, that in reference to 
position, I may offer the general rule : That for the easy reduction of a 
dislocated hip or shoulder, the limb should be placed in, as nearly as 
possible, the same position as that which most frequently characterizes it 
at the instant of escape." And speaking especially of dislocations of 
the femur upon the dorsum ilii, he adds : "If we now flex, adduct, and 
inwardly rotate to a still greater degree, we shall loosen the anterior and 
inferior tense untorn portion which is holding the head hooked outside 
the acetabular ridge, and then by a moderate amount of force we may 

Fig. 327. 




Relaxation of the ilio-femoral ligament by flexion. (Bigelow.) 

draw the head into the socket. This is most conveniently accom- 
plished by putting the patient on the floor on his back; an assistant 
fixes the pelvis ; the surgeon grasps the limb, flexes and adducts it till 
it crosses the limb of the opposite side at a point as high as the union 
of the upper with the lower two-thirds of the femur; now rotating the 
limb inwardly, he will be able to lift the head into place by a moderate 
effort." 

Reduction by extension dates from ;t period equally curly with reduc- 
tion by manipulation. Hippocrates recommended, when other and gentler 
means had failed, to make extension and counter-extension ; the extend- 
ing band- being made fast above the knee and above the ankle, so as to 
distribute the points of pressure; and the counter-extending bands being 
secured around the chest under the armpits, and also, if thoughl acces- 
sary, in the perineum of the Bound Bide. 






DISLOCATIONS OF Til E THIGH. 



Among the methods recommended and practised by Hippocrates, was 
Bitting e upper round of a ladder with a weight attached to the 

thigh of the dislocated limb; or suspending the patient from a sort of 
gallows with the head downwards, and if the weight of the patient's own 
body proved insufficient, the surgeon might add Ins also; a method which 
Hippocrates characterizes as u a good, proper, and natural mode of re- 
duction, and one which lias something of display in it, if any one takes 
delighl in such ostentatious modes of procedure." 1 

Willi various modifications as to the position of the limb, and as to the 
points upon which the extending and counter-extending forces are to be 
applied, and with differently constructed appliances, surgeons have con- 
tinued to employ extension down to this day. 

The great majority have regarded flexion of the thigh as essential to 
success ; some holding the limb only slightly flexed, and others insisting 
that flexion should be increased to a right angle with the body. 



Fig. 328. 




Bippocrates's mode of reducing dislocations of the bip by extension. 

The French surgeons, including Boyer and Vidal (de Cassis), prefer 
generally to apply the extending bands to the feet, in order that the 
muscles of the thigh may not be stimulated to contraction by the pres- 
Bure of the bandages. Mr. Ske} r adopts the same method. 

Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller, 

Til rio. Erichsen, and the English surgeons generally, make fast the lacq 

above the knee. J. L. Petit and Duverney, among the French, and 

ibson, with most of the American surgeons, recommend the 

I n iv Beeks to multiply the points of application, and for this 

purpose secures the extending band to the whole length of the leg, and 

mall portion of the thigh above the knee. 

Tin' counter-extending bands are now almost universally made to ope- 

r.it.' against the perineum of the dislocated limb, but Roux, following the 

ice of Hippocrates, places it in the perineum of the sound limb. 

m recommends the same practice. 

sara recommends that sometimes the reduction should be attempted 

•ii]. Iv placing th<' heel in the perineum and making the extension 

witli the hands, very much as Sir Astley Cooper advises us to proceed 

1 Works ■>!' Hippocrates, Syd. ed., London, vol. ii. p. 641. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 827 



in dislocations of the humerus. Morgan and Cock, of Guy's Hospital, 
Lave reduced six cases of dislocation of the hip-joint by placing the foot 
between the thighs, so that it pressed against the upper part of the dis- 
located bone, and thrust it away from the pelvis; extension and rotation 
of the limb being made at the same time by assistants. 1 Three of these 
were examples of dislocation upon the dorsum ilii, two upon the pubes, 
and one into the foramen thyroideum : and most of them had occurred 
in weak or elderly persons. 

Ambrose Pare was among the first to recommend the use of pulleys 
for the reduction of dislocations. Most surgeons since his day have 
employed them for the purpose of making extension more energetic and 
steady, and that it might be longer continued. Sir Astley Cooper's plan 
of procedure is as follows : 

Fig. 329. 




Reduction of a dislocation on the dorsum ilii, by pulleys. (Sir Astley Cooper's method.) 



The patient having been bled freely, and the muscles still farther 
relaxed by nauseating doses of antimony and by the hot bath, he is to be 
placed on his back upon a table of convenient height between two sta- 
ples ; a strong padded leathern girth or perineal band, constructed so as 
to receive the thigh, and to press at the same moment against the peri- 
neum and the outer surface of the pelvis, is then applied and made fast 
to one of the staples situated behind the patient in the direction of the 
axis of the limb. A wetted linen roller is next to be tightly applied 
just above the knee, and upon this a leathern strap is to be buckled, 
having two short straps with wings at right angles with the circular part; 
or. instead of this, a round towel made in the knot called the clove-hitch. 
The knee is to be slightly bent, but not quite to ;i right angle, mid 
brought across the opposite thigh ;i little above the knee. The pulleys 
being now attached, tin- extension is to be commenced. 

A very simple and efficient mode of making the extension, if one lias 
not the pulleys, is to employ for this purpose ;i -mall rope, the end.- being 
tied together, and the rope being then doubled upon itself once or twice. 
- to make four or eight parallel cords. The opposite *u<\< of tliis 
bundle of ropes being made fast to the limb and the staple, the extension 
is made by thrusting a stick through it- centre and twisting it. (Fig. 330.) 

1 Cock and Morgan, Chelius, op. cit., vol. ii. p. 242, note by South. 



DISLOCATIONS OF THE THIGH. 

I have Bevera] times had occasion to resort to this plan ; and indeed 
it has been for some time known and practised among surgeons in this 

Fig. 330. 




Redaction of a dislocation on the dorsum ilii, by the Spanish windlass. (Gilbert.) 

country. 1 having been first, according to Professor Gilbert, introduced 
by Fahnestock, of Pittsburg, Pa. It is usually known as the "Spanish 
windlass." 

Fig. 331. 




Jarris'a adjuster applied for reduction of a dislocation of the hip. 

Jarvis's adjuster, to which T have already made allusion when speak- 
'".- "f dislocations of the humerus, has been often used with success in 

1 Gilbert Iphia, note to Pirrie's Surg. ; also Amer. Journ. Med. Sci., vol. 

a p;!. 1845. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 



829 



dislocation of the hip as well as in dislocations of the shoulder. 1 Its 
power is equal to that of the pulleys, while the direction of the force can 
be' varied with much greater ease. 

Mr. Fergusson says that the Lancet for July 26, 1845, contains a 
description of a similar apparatus constructed by Coxeter at the sugges- 
tion of G. N. Epps; 2 and L'Estrange, of Dublin, has invented a "wind- 
lass" for making extension, with a "forceps," by which the extending 
power can be instantly disengaged. 3 Mr. Bloxham's "dislocation tour- 
niquet" is also very simple, and Mr. Erichsen affirms that by it "any 
amount of extending force that may be required can be readily set up 
and maintained." 4 Sedillot, a French surgeon, has suggested that when 
pulleys are used, we should measure the exact power employed in the 
reduction, by an ingeniously contrived apparatus called the dynanome- 
ter, 5 and which has been variously modified by Charriere, Mathieu, 
Robert, and Collin. 6 Such an instrument might occasionally be useful 
in preventing the application of excessive force, especially when the 
patient is under the influence of an anesthetic. 



Fig. 332. 




Bloxham's " dislocation tourniquet" applied for reduction of a dislocation on the pubes. 

Appreciation. — Finally, without attempting to determine the precise 
relative value of these different procedures, all of which claim for them- 
selves the testimony of experience, I am prepared to admit that no one 
of them is without merit, and that each may in certain cases possess ad- 
vantages over the others. Precisely what the cases are to which each 
individual method may be especially applicable, I believe it would be 
impossible to declare unless the cases were actually before me ; and even 
then it would probably be found difficult often to say which was the best 
until a fair trial of one or more, and a final success, had determined the 
question. The time has not yet arrived in which we may institute a 
rigid comparison between the relative merits of the two leading plans of 



1 Crandall, Boston Med. and Sur^. Journ., vol. xxxix. 
Med. Assoc, viii. p. :;.",:. I860. 

2 Fergusson, 4th Arner. ed , p. 200. 

4 Erichsen, Amer ed., 1868, p. 242. 

5 Amer. Journ. Med. Sci , vol. xv. p. 630. 

6 Poinsot, op. cit., p. 1038. 



. 77 : Atlee, Trans. Amer. 
3 Ibid., p. 198. 



B30 DISLOCATIONS OF THE THIGH. 

redaction, manipulation, and extension, for while it is true that reduction 
by manipulation has been practised from t he earliest day, it is equally 
true that extension lias been generally preferred and practised by sur- 
geons in all ages. Indeed, it was not until Dr. Reid, of Rochester, 
again called the attention of the profession to this subject, illustrating 
his views by the results of several successful experiments and by inge- 
aious arguments, that reduction by manipulation could be said to have 
been fairly introduced as an established method of practice; a large 
majority of all the eases upon record of reduction by manipulation 
having been reported since the year 1851, the period of Dr. Reid's first 
communication to the Buffalo Medical Journal. 

The following summary of a paper prepared by myself, with the view 
of determining, if possible, the relative value of the two methods, and 
exhibiting an analysis of sixty-four cases in which manipulation was 
employed, will enable the reader to form some estimate of the difficulty 
in which this subject is involved; and if it does not actually decide a 
moot-point, it will at least demonstrate that the method by manipulation 
is not without its hazards. 1 

" Of forty-one cases in which the fact is stated, twenty-eight were 
reduced on the first attempt, seven on the second, four on the third, and 
two on the seventh. In seven examples the head of the femur has been 
thrown from one position to another upon the pelvis, travelling from the 
dorsum of the ilium to the ischiatic notch, and from thence to the fora- 
men ovale: or directly from the dorsum to the foramen, and back again ; 
or in other directions, according to the character of the original disloca- 
tion ; in some instances these changes being made as often as seven times 
in succession. In the majority of cases no evil consequences seem to 
have followed upon these changes of position. One of my own cases will 
especially serve to show with what impunity sometimes these changes 
may be made. 

••do] m Caswell, set. 28, was admitted to the Buffalo Hospital of the 
Sisters of Charity on the 13th of January, 1858, with a dislocation of 
the left femur upon the dorsum ilii, which had occurred six days before. 
Ih- own account of the accident was that he was standing at the bottom 
of a well, bent forwards until his body was at a right angle with his 
thighs, when a bucket holding five hundred pounds of earth fell upon his 
back and hips. No attempt had been made to reduce the dislocation. 
Five times in succession manipulation made by myself failed, leaving the 
head of the bone each time upon the dorsum ilii; the sixth attempt, 
made with the addition of moderate extension by the hands, threw the 
head into tin- foramen thyroideum. By reversing the movements, it was 
easily replaced upon the dorsum ilii. The seventh trial was made in 
the same manner, except that when I supposed the head of the bone to 
be opposite the lower margin of the socket I did not permit the limb to 
turn either outwards or inwards, but while lifting at the knee with my 
bands, with sufficient power to raise his hips from the table, I brought 

of Dislocation of the Femur by Manipulation. By the Author. Buf- 
M edicalJournal, Nov. 1857; Feb., March, June, 1859. With tables constructed 
by my very intelligent pupil, Lucien Damainville. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 831 

the limb down gradually to a line parallel with the opposite, and thus 
finally the reduction was accomplished. No pain or inflammation fol- 
lowed, and in two weeks he left the hospital ; but whether he was able 
to walk or not at that time, I am unable to say." 1 

Since this paper was written, the following cases have come to my 
knowledge. December 9, 1865, Dr. James R. Wood attempted, at the 
Bellevue Hospital, the reduction of a dislocation of the femur upon the 
dorsum ilii. of five months' standing, in a man sixty years of age, in the 
presence of Dr. Sayre, myself, and the class of medical students. The 
patient was under the influence of ether. Manipulation alone was em- 
ployed. Probably half an hour had been consumed in the various 
efforts, when, at a moment when the thigh was being forcibly abducted, 
the neck was broken within the capsule, and very close to the head. I 
was able to feel the head of the bone distinctly, after the fracture, and 
to move it freely separated from the neck. 

Dr. David Prince, of Illinois, who was present at the time, informed 
me that he had himself fractured the neck of the femur in attempting 
the reduction of an ancient dislocation of the hip by manipulation. 

In Markoe's paper, published in the New York Journal for January, 
1855, several cases similar to that of Caswell are reported, in which the 
results have been equally fortunate ; but the case mentioned as having 
been under the care of Dr. Post, had a more serious termination. This 
patient, John Kelly, get. 21, had a dislocation into the ischiatic notch, 
and on the same day the reduction was attempted by manipulation. On 
the first trial the head of the bone was thrown into the foramen ovale ; 
and, after having been moved backwards and forwards between these 
two points several times, it was finally carried directly from the foramen 
ovale into the socket by manual extension applied in the ordinary way, 
but without pulleys. " In this case," says Markoe, "the cure w r as very 
slow, and he left the hospital with some degree of pain and swelling 
about the joint. I learned that an abscess formed in or about the joint, 
which was opened, and wmen I saw him, a year after, there was every 
appearance of seated morbus coxarius." 

In Case 14, of Markoe's paper, the thigh was broken at the neck after 
manipulation had been employed, but while extension was being made 
by the hands, united with "a lifting outwards." Whether the fracture 
was due to the extension, or to the manipulation, seems not to be clearly 
determined. The dislocation had existed seven weeks when this attempt 
at reduction was made. 

Dr. Bigelow has reported a case of dislocation upon the dorsum, of 
six months' standing, in a man 23 years of age, which he attempted to 
reduce, and caused a fracture of the neck of the femur. His account of 
the manner in which the accident occurred is as follows: " I flexed the 
limb once slowly upward upon the abdomen — a movement which was 
attended with a continued fine crepitation about the hip." Opon exami- 
nation, the head of the bono was found to be separated from the neck. 

Dr. Dawson has reported to the Cincinnati Academy of Medicine a 
case in which this accident occurred in his hands. Captain Williamson, 

1 Buffalo Medical Journal, vol. xiii. p. 682. 



DISLOCATIONS OF THE THIGH. 

a gentleman in middle life and fair health, was received at Dr. Dawson's 
clinic with a dislocation into the ischiatie notch of nine weeks' standing. 
Be was placed under the influence of ether, and various methods of 
manipulation employed. At last " more force was used, the thigh was 
pic— ed forcibly across the abdomen," and this was followed by rapid 
circumduction. At the sixth repetition of this manoeuvre, the neck of 
the bone Buddenly gave way. 1 

Dr. J. S. Wight, of Brooklyn, broke the femur in an attempt to re- 
duce a dislocation of four months' standing. The patient was fifty-three 
vcars old, and the head of the femur was thought to be in the ischiatic 
notch. Under ether the thigh was flexed upon the body, and then ad- 
ducted with moderate force, when it broke with a loud snap just below 
the trochanter. The fragments subsequently united. 2 

A lad, aet. 15, fell through a hatchway, dislocating the left femur 
upon the dorsum ilii. The surgeon first called did not recognize the 
accident. April 29, 1873, eight weeks and one day after, this patient 
was received into St. Francis's Hospital, and reduction attempted by Drs. 
Rose and Lellman, both gentlemen of experience. It was reduced (ap- 
parently) with ease, the patient being under the influence of ether. 
Extension, with a six-pound weight, was applied to the limb, in order to 
Becure quiet, and three days later they found the bone out of place, and 
they repeated the attempt at reduction by manipulation. It was now 
ascertained that the neck of the femur was broken, but whether this 
accident happened in the first or second attempt is not quite certain. 
Two days later I saw the patient, and found the limb shortened one inch 
and a half, and rotated outwards when unsupported. The head of the 
bone could be felt on the dorsum. 

Dr. Rose informs me that Dr. Krackowizer told him that he had just 
met with the same accident. 

Assisted by my pupil, Mr. Hodge, I have also succeeded in collecting 
sixty-two cases of attempts at reduction by extension ; a great majority 
of which, we find, were reduced in the first trials; but five cases of 
recent dislocation were not reduced until after several attempts had been 
made. 

In five cases the femur was broken. The first occurred in St. Thomas's 
Hospital, London. Ben. Whittenburg, get. 40, was admitted Nov. 4, 
1827, with a dislocation into the ischiatic notch, of twenty-two weeks' 
duration. After bleeding, etc., had been practised, an attempt was 
made to reduce the bone by pulleys, in which the reporter professes to 
believe they \\<Te successful, but on the following day it was plainly 
enough qoI in place. Mr. Travers again resorted to extension, and while 
extension was kepi up and the assistants were rotating the limb out- 
wards, the Deck of the femur gave way. 3 Malgaigne mentions a case 
in which, while he was himself directing the operation, the thigh was 
broken through its lower third. He was attempting to reduce the bone 
Ion, but it was not until he gave the signal for rotation out- 

1 Dawson, The Clinic, Oct. 17, 1874. 

Wight, II. -p. Gazette, Sept. 13, 1879. 
1 London Med.-Chir. Rev., Nov. 1828, p. 239. 



UPWARDS AND BACKWARDS OX THE DORSUM ILII. 833 

wards that the bone gave way. 1 Gibson says that Dr. Physick, at the 
Pennsylvania Hospital, while engaged in reducing a dislocated thigh by 
the pulleys, broke the femur in consequence of exerting too much force 
upon it in a lateral direction by an additional pulley ; and that a similar 
accident is supposed to have happened to Drs. Harris and Randolph in 
the same hospital, in the year 1838, while using the pulleys upon a boy 
twelve years of age ; for during extension and counter-extension, at the 
moment of rotating the limb, and of drawing it forcibly outwards by a 
towel, a sudden crack was heard. - 

The fifth case is related by Sir Astley Cooper as having occurred at 
the Brighton Hospital, under the care of Mr. Gw} r nne ; the dislocation 
was upon the dorsum ilii. and was supposed to have existed about one 
month. The neck of the femur was broken in the first attempt at re- 
duction, and while the surgeon was making extension, with gentle 
rotation. 3 

Sir Astley says : " There are plenty of cases upon record, of fatal 
abscesses from violent attempts at the reduction of dislocated hips." I 
presume that this remark has reference to attempts at reduction by ex- 
tension, since, in his day, this was almost the only mode in use among 
surgeons. He adds, moreover, that Mr. Skey has mentioned, in the 
Lancet* a fatal case of phlebitis following protracted extension of the 
thigh. Malgaigne has collected no less than eight similar examples, with 
several more in which serious consequences and even death followed 
promptly upon violent attempts at reduction by mechanical means. 5 

Marchand 6 has reported three cases of paralysis ensuing upon at- 
tempts at reduction by extension ; in one of which, however, some doubt 
remains as to whether it was due to the extension. 

The head of the bone has been repeatedly thrown from the dorsum 
ilii into the ischiatic notch: and B. Cooper mentions a case in which the 
bone was carried from the foramen ovale into the ischiatic notch, from 
which latter position it could not afterwards be changed. 7 

Aa to the relative chances of failure by the two methods, the testi- 
mony of the recorded cases is equally unsatisfactory. Of the failures 
by extension, the experience of almost every surgeon, the journals, and 
the treatises furnish a sufficient number of examples; while among the 
sixty-four cases of attempts at reduction by manipulation collected by 
me, and, excepting the cases in which the bone was broken, only two 
were positive failures. It is somewhat remarkable, however, that these 
two cases occurred in the experience of the New York City Hospital : 
and that they are taken from a total of fifteen, this being the whole 
number which had been treated by this method at the date of these ob- 
servations, in the New York Hospital. One had existed one month, and, 
after repeated trials by manipulation and frequent changes of position, 

1 Malgaigne, op cit., vol. ii. pp. 146 and 880. 
1 G-i - n's 8 ugery, sixth ed., vol. i. p. 389. 

3 Sir Astley Oooperou Disloc., Amer '•')., p. 88. 

4 Op. cit., vol. i. j) 767, 1840 11. Cooper on Disloc., ]>. 69. 

5 Malgaigne, op. cit . vol. ii. p. 164 el seq 
Marchand, Th< tion, Pari-. 1875, p. 7''.. 

7 Sir Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96. 



384 DISLOCATIONS OF THE THIGH. 

it was finally reduced by pulleys. The other, a dislocation into the 
ischiatic notch, had existed only a few hours. At least seven or eight 
trials were made to accomplish the reduction by manipulation, but with- 
out success. The firsl attempt by extension failed also, but in the second 
attempt the femurwas kept at a right angle with the body, and the bone 
was -""ii brought into its socket. 1 

We have in these two examples not only a record of failure by man- 
ipulation, but an equal record of success by extension; while, on the 
other hand, we find, in an analysis of the sixty-four cases, sixteen triumphs 
«.f manipulation over extension. 

1 must not omit to mention, in order that the reader may form a 
just estimate of the value of these statistics, that the great majority, es- 
pecially of the cases treated by manipulation, have occurred in private 
practice, and it is unnecessary to say that such statistics do not furnish 
the most reliable basis for conclusions. As a general rule, unsuccessful 
cases are not published by private practitioners, but successful cases are 
pretty certain to be made known; while, on the other hand, a series of 
cases furnished by any single hospital will generally be found to have 
given both unsuccessful and successful cases. The writer has heard 
lately of a complete failure to reduce by manipulation in a recent disloca- 
tion of the hip, after repeated efforts on several successive days, and 
where skilful surgeons were in attendance; but it is believed that no 
account of the result has been published. 

I have already called attention to the fact that, in the New York 
City Hospital, two of the fifteen cases reported were failures; a circum- 
Btance of remarkable significance, especially when we consider the skill 
of the BeveraJ gentlemen who were the operators in these cases; and it 
plainly renders a new series of statistics necessary, drawn solely from 
the experience of one or more similar large establishments, before we 
>hal] he prepared to decide positively upon the relative value of the two 
procedures. 

Nevertheless, I shall not hesitate to express my present convictions 
upon this subject, reserving to myself the right of a change of opinion 
whenever the proofs shall warrant it. 

Manipulation, owing to the greater power which may be brought to 
hear upon the ueck and head of the bone through the action of the shaft 
of the femur as a lever, is most liable to throw the head of the bone 
into new positions, and consequently most liable to rupture the various 
sofl tissues about the joint; to produce inflammation, suppuration, and 
caries. For the same reason it is most liable, also, to fracture the neck 
of the femur. It is not certain in my mind but that, when the princi- 
ples which control the reduction are more completely understood, these 
evils may be lessened; yet I can scarcely persuade myself that by 
any future observations the state of the question will ever be greatly 
changed. I cannot but think, also, that some conclusions ought to be 
drawn from the circumstance that, since the time of Hippocrates to the 
present day. manipulation lias been occasionally recommended and suc- 
cessfu] examples reported; the reduction being accomplished in most in- 

1 Van Buren, New York Med. Times, Jan. 1856, p. 126. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 835 

stances by processes identical, or nearly so, with those now adopted ; yet 
generally the writers appear to have been ignorant of what had been 
done before, and, indeed, they have generally avowed their belief that 
the method suggested by themselves was altogether new and original. 
Possibly this slowness to establish, and total inability to sustain and per- 
petuate a reputation, was not the fault of the method, and had no rela- 
tion to its failures. Until within a few years the number of surgical 
books, and especially of medical journals, was comparatively very small, 
so that valuable truths often died with their discoverers, or w r ere known 
and remembered only by a few; but it is possible, also, that it has a 
deeper significance, and that it implies some defect in the procedure, or 
serious danger, in consequence of which it has from time to time lapsed 
into desuetude and finally into complete oblivion. 

The Author's Method of Manipulation. — The rules which the author 
would, give for the employment of manipulation are very simple. 

Fig. 333. 




The Author's method. Fir.-t position. 

The patifM being laid on his back upon a mattress, the surgeon, as- 
suming that it is ;i dislocation upon the dorsum ilii. should seize tli<' fool 
with on'- hand and the other he should place under the knee; then, flex- 
ing the leg upon the thigh, the knee Is to be carefully lifted toward the 
face of the patient until ir meets with some resistance; it musl then !><• 
moved outwards and slightly rotated in the same direction until resist- 
ance is again encountered, when it musl be gradually brought downwards 



836 



DISLOCATIONS OF THE THIGH. 



again to the bed. I do not know that the whole process could be 
expressed in Bimpler or more intelligent terms than to say, that the 
limh should follow constantly its own inclination. 

Fig. 334. 




Second position. Not often required. Liable to cause secondary dislocation into ischiatic 
notch or foramen ovale. 

All writers have united in the necessity of flexion ; and, indeed, with 
vow few exceptions, the advocates of extension have insisted upon carry- 
ing the dislocated limb more or less across the sound one; or of making 
the extension at right angles with the body. They have also been 
nearly unanimous in their statements that the thigh should then be ab- 
ducted and finally brought down. Nathan Smith has added the injunc- 
tion ro rotate the shaft of the femur outwards, and to press gently upon 
the inside of the knee while the thigh is being flexed upon the body, so 
;i- to compel the head of the bone to hug the outer margin of the ace- 
tabulum and to prevent its falling into the ischiatic notch; a suggestion 
which has been erroneously interpreted by some writers to mean that he 
would carry up the limb abducted, a tbing which is simply impossible 
until the reduction is accomplished. In adopting this practice, however, 
rnusl nor forgel the danger which we incur, when the limb is com- 
pletely flexed, and the bead of the femur is below the edge of the ace- 
tabulum, of throwing it over into the foramen ovale. Dr. Nathan Smith 
has also noticed the advantage which sometimes may be gained by giving 
to the limb at tin- moment a Blight rocking motion. 



UPWARDS AND BACKWARDS OX THE DORSUM 1LII. 837 

These movements of the limb, with perhaps other slight modifications, 
such as lifting the knee moderately or forcibly when the bone refuses to 
mount over the margin of the acetabulum, pressing with the hand or foot 
upon the pelvic bones, ami violent circumduction, are all which have been 
usually practised in successful manipulation. 

Fig. 33-3. 




Third position. 

I repeat, however, that as a general rule, in the first trial, the knee 
must be carried only in those directions which offer no resistance, and 
these will be found almost always to be the same ; the knee of the dis- 
located femur hanging over the sound one will be made easily to ascend 
to about a right angle with the body; we can then carry it outwards a 
short distance, probably not more than four or five degrees; at this 
moment, frequently, the thigh will begin to rotate outwards of itself and 
with considerable force, or, as Wathman says, "a self-twisting of the 
thigh occurs, which cannot b<- prevented by fast holding." When this 
action takes place, the reduction is immediately accomplished : and it is 
in fact at this moment, before the limb begins to descend, that the hone 
most frequently resumes it- socket. If it does not, then as soon a- the 
limb begins to fall the reduction occurs, generally with a loud snap. It 
is pretty certain that this manipulation is to fail if the knee has descended 
more than a few inches without the reduction having taken place: and 
it will be better to repeat the manoeuvre at once, rather than to bring the 
limb completely down. 



DISLOCATIONS OF THE THIGH. 

Generally anaesthetics ought not to be employed, since the operation, 
It' successful, is Dot usually painful, and we need that the patient should 
preserve his consciousness, in order to admonish us when we are using 
improper violence. It is probable, also, that the action of certain muscles 
Bometimes affords material assistance in the reduction. If, however, the 
patienl is very sensitive, or the parts about the joint are very tender, or 
manipulation without anaesthetics has failed, then certainly these agents 
may be properly and advantageously employed. 

[f we propose to attempt reduction by extension, it is no longer neces- 
sary to resort to the lancet, antimony, and the hot bath, as preliminary 
measures, Bince the muscles can be at once overcome by the much more 
certain and more powerful agents, chloroform, ether, etc. 

Sir Astley Cooper' 8 Method of Extension. — The method recom- 
mended by Sir Astley Cooper, and most often practised by surgeons of 
the present day, is essentially as follows: 

The patient is placed upon a bed of suitable height, reclining on his 
back, but partly over upon the sound side. Observing now the line of 
the axis of the dislocated thigh, one strong staple is to be secured into 
the Avail upon one side of the room, and another upon the opposite side, 
both of which shall correspond as nearly as possible with the line of the 
shaft of the femur. The staple in front of the body will be higher than 
the bed. and the staple behind will be, in the same proportion, lower 
than the bed. The iimb being stripped, two pieces of strong factory 
cloth, each about four inches wide and two feet long, should be laid 
parallel with and on each side of the limb; the centre of each strip 
being about opposite that portion of the thigh which is just above the 
two condyles. Over the centre of these strips, above the condyles and 
patella, a strong roller, three inches wide and at least three yards long, 
previously wetted in water, is to be turned as tightly as it can be drawn 
until the whole roller is exhausted; the extremity of the roller being 
made fast with a needle and thread rather than with pins. The upper 
end- of the side strips are then to be brought down, and tied to the 
Lower ends, forming thus two lateral loops, upon which one of the hooks 
of the compound pulleys is to be made fast, while the other hook is 
secured to the front staple in the wall. Instead of these rollers we may 
employ, if we choose, a leathern thigh-belt. For the purpose of counter- 
extension ;i sheel is folded diagonally, and its centre being applied to 
the perineum of the dislocated limb, the ends are tied firmly into the 
back staple. To prevent the body from moving laterally, under the 
action of the pulleys, one assistant should be seated upon the bed, with 
bis back against the side and back of the patient, and his right arm 
thrown over the body : it is well also to station another beside the sound 
limb. -.. ;i- to retain it also in its place upon the bed. Underneath the 
upper part of the dislocated limb a strong and broad bandage should be 
placed, of sufficienl length to tie over the neck of the surgeon when he 
ading about half-bent over the body of the patient. 
rything being arranged, and all portions of the apparatus having 
sufficiently tested to make sure that nothing will give way during 
operation, the anaesthetic is to be administered, and as the patient 
gradually under its influence, the action of the pulleys should com- 



UPWARDS AXD BACKWARDS ON THE DORSUM ILII. 839 

mence, and be slowly but steadily increased ; a third assistant managing 
the rope, so as to leave the surgeon unembarrassed, and able to direct 
his whole attention to the position of the trochanter major and of the 
head of the femur. In order to this, he should place one hand upon 
each of these prominences, and watch carefully their descent. 

The length of time which will be required to bring down the limb 
must differ greatly in different persons, according to the peculiar cir- 
cumstances of the case, and the condition, age, etc., of the patient; but 
it must never be forgotten that a slow and steady action is much more 
effective than rapid and irregular tractions, and it is in this especially, 
rather than in the relative amount of power, that the pulleys possess 
always so great an advantage over the hands. 

When the surgeon finds that the head of the bone has nearly or quite 
reached the socket, if it does not take its place spontaneously, he may 
place his neck in the noose which passes underneath the thigh, and lift 
upwards and outwards, in order to raise the trochanter major, and thus 
enable the head to rotate toward the acetabulum. It is in this part of 
the manoeuvre, and especially when at the same moment one of the 
assistants, after bending the leg upon the thigh so as to make of it a 
lever, has rotated the thigh outwards, that the fracture of the neck has 
generally taken place ; and we cannot be too cautious, therefore, parti- 
cularly in old persons, not to bear very strongly upon the noose, nor to 
permit the assistant to rotate outwards with great force. 

If the bone does not enter the socket, we may increase the flexion, or 
suddenly release the tension, or, in fine, again resort to manipulation 
alone. 

When the reduction is accomplished, the patient should be laid upon 
his back, with the knees resting over a pillow, and tied together lightly 
with a towel or a strip of cotton cloth. In order also the more certainly 
to prevent a redislocation, the thigh of the dislocated limb should be gently 
rotated outwards, by which the head will be pressed forwards against 
the anterior portion of the capsule. 

Such an accident, however, as a recurrence of the dislocation, in the 
case of the femur, is exceedingly rare ; and I should have deemed it 
altogether impossible, except as the result of considerable violence again 
applied, had not at least two examples been reported to me upon very 
excellent authority. Malgaigne says he has himself seen an example of 
redislocation upon the dorsum ilii. occasioned by an untimely movement; 1 
and Verneuil has seen, ten days after the reduction of a dislocation 
upon the ischiatic notch, the dislocation reproduced by a sudden effort 
of the patient to sit up ; 2 indeed, it is when the limb is in a flexed posi- 
tion that the accident seems most likely to occur. 

Of course, in these remarks I mean to except those cases in which 
the upper margin of the acetabulum is broken off, and the head of the 
femur has consequently lost it- Datura! support in this direction. 

The possibility of this accident is also confirmed by the examples of 
"voluntary" dislocations, which I shall relate in the lasl Bection of this 
chapter. 

1 Malgaigne, op.cit., torn. Li. | [bid., p. 840. 



840 



DISLOCATIONS OF THE THIGH. 



Bigelow'a Method of Extension. — The method of extension recom- 
mended by Dr. Bigelow, namely, with the thigh at a right angle with 
the body, has already been referred to; and there is much reason to 
believe that, aa a rule, it is preferable to extension as practised by Sir 
v Cooper. Nearly all surgeons, however, have recognized the ne- 
cessity of flexing the thigh in certain cases. Dr. Bigelow suggests that 
where greater force is required than can "be obtained by the usual methods, 
B tripod should be employed, as shown in the accompanying woodcut. 

Fig. 336. 




Tripod for vertical extension. (Bigelow.) 



The following case, reported to me by Dr. N. Fanning, of Catskill, 
N. Y.. illustrates the occasional necessity of resorting to extension, and 
i- of special interest on account of the extreme youth of the patient. I 
have referred to the same case once before. 

A little girl, two and a half years old, was caught under a falling door 
on the 24tb of May. 1867, but her parents suspected no injury beyond 
ere bruise until ten days later, when they consulted Dr. Fanning. 
The left femur was then found to be dislocated upon the dorsum ilii. Dr. 
Fanning attempted first to reduce the dislocation by manipulation, but 
he failed. He then directed the Father to make extension by the legs, 
while th<- mother made counter-extension by seizing the child under the 
arms, and thus he soon succeeded in effecting the reduction. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 841 



$ 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch. 

Syn. — •• Upwards and backwards into the ischiatic notch ; ; ' Sir A. Cooper. "Up- 
wards and backwards into the great sacro-sciatic notch ; " Li/ars. " Backwards into 
the sacro-sciatic foramen ; ,: S. Cooper. "Backwards into the ischiatic notch ;" Liston, 
B. Cooper. Miller, Pirrie, Erichsen, Skey, Gibson. " Downwards and outwards on 
the os ischium:" Boyer, Dorsey. "Backwards and downwards into the ischiatic 
notch;'-' Chelius, Petit. Duverney. "Upon the ischium; 1 ' Bertrandi. ''Sacro- 
sciatic:" Gerdy. "Ischiatic;" 3Ialgaigne. " Dorsal below the tendon ;" Bigelow. 

Boyer considers this dislocation as only secondary upon a dislocation 
upon the dorsum ilii; but it is very certain that it often occurs as a 



Pig. 337. 



Pig. 338. 




Dislocation upwards and backwards into 
the great ischiatic notch. (A. Cooper.) 

primary accident. Not unfre- 
quently, also, what was pri- 
marily a dislocation into the 
ischiatic notch, becomes subse- 
quently a dislocation upon the 
dorsum ilii. 

Causes. — A fall upon the 
foot or knee when the limb is 
very rnucli in advance of the 
body; or the fill of ;i heavy 
weight upon the back and 
pelvis when the thigh is nearly 

or quite at a right angle with the body. Indeed, the 
similar to those which produce dislocations upon the dor 




location upwards and backwa 
ischiatic notch 



rdi, into : b 



causes 
•sum il 



are very 
i. except 



B42 DISLOCATIONS OF THE THIGH. 

that it is necessary to suppose the Limb in a position more nearly at a 
right angle with the trunk, at the moment at which the force is applied. 
Pathological Anatomy. — Mr. Syme, who dissected the body of a man 
recently dead, whose thigh had been dislocated into the ischiatic notch, 
found the glutseus maximus nearly torn asunder, the head of the femur 
being embedded in its substance; the glutseus minimus, the pyriformis, 
and the gemellus superior lacerated ; the capsular ligament extensively 
torn close to the edge of the acetabulum, and the round ligament 
completely separated from the femur. The head of the femur was lying 
in the great ischiatic notch, upon the gemelli and the sacro-sciatic nerve, 
behind the acetabulum and a little above it; being situated between 
the upper margin of the notch and the great sacro-sciatic ligaments. 1 
Figure 337 is a representation of this specimen. 

Fig. 339. 

^#Sr few 




Internal obturator in its natural position. (Bigelow.) 

Dr. Joseph C. Butchison, of Brooklyn, N. Y., has reported an exam- 
ple of this dislocation in which, death having occurred four days after 
reduction, he was able to ascertain the character of the lesions. By the 
courtesy of Dr. Eutchison, 1 was permitted to be present at this autopsy, 
and the Lesions wen; found to be much the same as in the case related by 
: bul the gluteeus minimus was not torn, and there was added a 
laceration of the obturator externus. Dr. Lente has reported one other 
dissection made after reduction. 2 

Dr. Bigelow Bpeaks of a dorsal (upon the ilium) dislocation as some- 

1 A.mer. Journ. .Mod. Sci., vol. xxxii. p. 4G0. 

2 Lente, New York Journ. Med., Jan. 1851. 



UPWARDS AXD BACKWARDS IXTO ISCHIATIC NOTCH. 843 



times occupying a position as low as the upper portion of the ischiatic 
notch : but the dislocation now under consideration he describes as that 
in which the head of the femur, having been driven from its socket 
downwards and backwards, is subsequently, in the attempt to straighten 
the limb, carried upwards behind the socket until it is arrested by the 
strong tendon of the obturator interims, and the subjacent capsule. This 
is usually denominated ••ischiatic:" but 
as it is both behind and below the ten- 
don, Bigelow calls it "dorsal below the 
tendon."' 

Prof. Gunn makes no mention of the 
relations of this dislocation to the tendon 
of the obturator interims, but only speaks 
of it as a "backward dislocation." 

Quain 1 made a careful dissection of a 
recent ischiatic dislocation, in which no 
attempt at reduction had been made. 
The head of the femur rested upon the 
ischiatic spine, and was separated from 
the pelvic bones only by the obturator 
internus and the gemelli. The pyrami- 
dalis, situated above the head of the 
femur, was moderately stretched. The 
gemelli and obturator internus were 
greatly stretched : which last-mentioned 
muscles, with the capsular ligament, alone 
separated the head from the cotyloid 
cavity, and from the surface of the in- 
nominatum situated behind this cavity. 
The external obturator and the quadra- 
tes were torn transversely. The capsule 
was detached from the cotyloid margin at its inferior and internal inser- 
tions, while its posterior and external portions were intact. The round 
ligament was torn from its insertion into the head of the femur. 

In a case reported by Scott. 2 the sciatic nerve was compressed between 
the head and the ischium. 

Symptoms. — The position of the limb is in -erne eases nearly the same 
a- in c.-i-rain dislocations upon the dorsum. It is shortened usually about 
half an inch, the thigh being Hexed upon the body, adducted, and rotated 
inward-: but the flexion is often less than in dislocations upon the 
dorsum, while, on the other hand, it issometimes much greater. Gener- 
ally it is such that, when the patient is standing, the end of* the gr< 
of the dislocated limb touches the ball of the great toe of the sound limb. 

Bigel hat the extreme flexion which issometimes found to 

exist, especially when the patient is in the recumbenl position, is generally 
due to the arrest of the head of the femur by the internal obturator and 
the subjacent untoro capsule. When the patient rises, the weight of the 




Showing tense condition of anterior 
half of capillar ligament in " back- 
ward " dislocation. (Gunn.) 



1 Quain. Poineot. op. cit., p. '' 
1 S tt, Dul lin Hosp. 1: 



844 



DISLOCATIONS OF THE THIGH. 



limb may Force the head up behind the tendon of the obturator ; or if 
the limb is brought down with force, the tendon and capsule may give 



Fio. 341. 




Internal obturator in its new position. (Isehiatic) " Dorsal below the tendon." (Bigelow.) 

way and the head may ascend to any 
point upon the outer surface of the 
ilium, and in this way an isehiatic may 
be converted into an iliac dislocation. 

The head of the femur is sometimes 
distinctly felt in its new position, 
especially when the limb is moved 
upwards or downwards. The tro- 
chanter major is approximated toward 
the anterior superior spinous process 
of the ilium. 

Sir Astley Cooper remarks that 
this dislocation is the most difficult to 
detect, and Mr. Syme mentions a 
case in which the nature of the acci- 
dent was overlooked by himself, and 
the thigh was not reduced until the 
thirteenth day ; l and subsequently 
Mr. Syme has called attention to 
what he considers as one of the most important diagnostic marks — indeed, 
er absent, nor is it ever met with in any other injury of 




upward! and backwards into 

■■ Below I tie tendon," 

when t ecumbent. (Bigelow.) 



Journ. Med. Sci., vol. xvi 



UPWARDS AND BACKWARDS INTO ISCH'IATIC NOTCH. 845 

the hip-joint, "whether dislocation, fracture, or bruise;"' this is "an 
arched form of the lumbar part of the spine, which cannot be straight- 
ened so long as the thigh is straight, or on a line with the patient's trunk. 
When the limb is raised or bent upwards upon the pelvis, the back rests 
flat upon the bed ; but so soon as the limb is allowed to descend, the 
back becomes arched as before." 1 This position, assumed by the back 
when an attempt is made to straighten and depress the limb, is due to 
the action of the psoas magnus and iliacus interims. But this can hardly 
be regarded as absolutely diagnostic, inasmuch as this same phenomenon 
will be observed in a degree, more or less, in a dislocation upon the 
dorsum, and in most cases of disease of the hip- joint. The inversion of 
the toes, immobility of the limb, and the absence of crepitus, are generally 
sufficient in themselves to distinguish it from a fracture of the neck. Dr. 
Squires, of Elmira, X. Y., in a note addressed to me in March, 1860, 
suggests, also, that in ancient cases the projection of the head of the 
femur may be felt by passing the finger into the rectum or vagina. With 
my finger in the rectum I determined a dislocation into the ischiatic 
notch which had existed six months, in a boy twelve years old ; and by 
exploration per vaginam I diagnosticated the same dislocation in a woman 
at Bellevue Hospital, which had existed four weeks. 

Dr. Oscar H. Allis, of Philadelphia, has added another valuable means 
of diagnosis, namely, that, although the limb, when laid parallel with the 
other, or as nearly so as it is practicable to place it, and extended, will be 
found to be only very little shortened, if at all ; yet, when the two limbs 
are brought into a position of flexion, the thighs being at right angles 
with the body, the dislocated limb will appear one or two inches shorter 
than the other — that is, the knee of the dislocated limb will be on a much 
lower level than the other. 2 

Dr. W. Dawson, of Cincinnati, whose observations in relation to this 
new sign extended back as far as 1871, and who had repeated the ob- 
servation several times, published his experience in 1878, without being 
aware that Dr. Allis had already called the attention of the profession 
to this point. 3 

Prognosis. — I have seen two dislocations of this character which 
were not recognized by the surgeons at the time of the receipt of the 
injury, nor for some weeks afterwards. One was in a lad twelve yv.ir* 
old. who was brought to me from an adjacent county in August, 1847. 
The accident bad happened eight weeks before. His limb was shortened 
one inch ; it was also forcibly adducted and rotated inwards. Dr. Cole- 
■ . ;i very excellent surgeon, had made a thorough attempl to reduce 
the dislocation with pulleys ;i few days before lie was brought to me, and 
I did not deem it advisable to subject him again to the trial. Notwith- 
standing the dislocation, his limb was quite useful. The second was in 
the case of the hoy seen by Dr. Sayre and myself, to which I have just 
referred. 

1 Amer. Journ. M I t. 1848, p. 161, from Loud, and Edinb. Month. Journ., 

July, 1843. 

Lllis, Phila. MM. Times, March 28, 1874. 
3 Dawson, Archives of Clinical Burg., .Inn. 1. 1878. II- sp. Gaz., May 16, L878. 



846 DISLOCATIONS OP THE THIGH. 

Treatment. — In employing manipulation, we may follow, with only 
a Blighl modification, the directions already given in dislocations upon 
the dorsum ilii. We find the head of the femur lower; consequently the 
extent of the circuit to be described in the manoeuvre is diminished, but 
in oihcr respects the processes are identical. 

We mast not forget, however, that there is especial danger, while 
attempting to reduce this dislocation by manipulation, that the head of 
the hone will be thrown across into the foramen thyroideum. I have 
already mentioned one case occurring under the care of Dr. Post in the 
New York Hospital, in which the head of the femur, originally in the 
ischiatic notch, passed backwards and forwards between the ischiatic notch 
and the foramen thyroideum many times, and which, although the reduc- 
tion was finally accomplished, was followed by morbus coxarius. Parker 
mentions a second case in the same paper, 1 in which his first attempt to 
reduce by manipulation carried the head of the bone into the foramen 
thyroideum ; but the second attempt was successful. In Dr. Hutchison's 
case, to which I have already referred, the first attempt at reduction was 
made without an anaesthetic, and by manipulation after the method de- 
Bcribed by Reid. The first two attempts failed, and in the third, the 
limb being more abducted than before, the head of the bone was thrown 
into the foramen thyroideum. By reversing the movements, it was re- 
placed in the ischiatic notch; and this change of position was made seven 
or eight times. The patient was now etherized, and the bone was lifted 
into its socket in the same manner which I have described in the case of 
Caswell. Malgaigne refers to a patient of Lenoir's, and to another of 
his «»wn. in which the head of the bone was lodged under the margin of 
the acetabulum during the attempts at reduction. 2 

On the 2od of March, 1855, Charles McCormick, set. 21, a laborer on 
the " State Line Railroad," was caught between two cars, with his back 
resting agajnst one car, and his right knee against the other, the right 
thigh being raised to a right angle with his body. As the cars came 
her ho felt a •• cracking" at his hip-joint, and found himself imme- 
diately unable to walk or stand. 

Two hour- after the accident, assisted by my son Theodore, and 
Austin Flint, dr.. I examined the limb carefully, and made arrangements 
for the reduction witli the pulleys, in case the attempt by manipulation 
should fail. 

The patienl lying upon his hack, I seized the right leg and thigh with 
my hands, the leg being moderately flexed upon the thigh, and carried 

tic ki -lowly up toward the belly, until it had approached within 

twelve or fifteen inches, when, noticing a slight resistance to farther prog- 
resa in this direction, I carried the knee across the body outwards, until 
ii encountered a slight resistance, and immediately I began to 
allow the limb to descend. At this moment a sudden slip or snap oc- 
curred Dear the joint, and I supposed reduction was accomplished; but 
on bringing the limb down completely, I found it was still in the ischiatic 
notch. 1 think the head had slipped off from the lower lip of the ace- 
i a. after haying been gradually lifted upon it. 

; Harkoe's paper, X. Y. Journ. of Med., Jan. 1855. 
- Malgaigne, op. cit., torn. ii. p. 839. 



UPWARDS AXD BACKWARDS INTO ISCHIATIC NOTCH. 847 

Without delay I commenced to repeat the manipulation, and in pre- 
cisely the same manner. Again, at the same point, when the limb was 
just beginning to descend, a much more distinct sensation of slipping was 
felt, and on dropping the limb it was found to be in place and in form, 
with all its mobility completely restored. 

No anaesthetic was employed, and no person supported the body or 
interfered in any way to assist in the reduction. No outcry was made 
by the patient, yet lie informed me that the manipulation hurt him con- 
siderably. The amount of force employed by myself was just sufficient 
to lift the limb, and the time occupied in the whole procedure was only a 
few seconds. 

After the reduction he remained upon his back, in bed, eleven days, 
in pursuance of my instructions. At the end of this time he began to 
walk about, but was unable to resume work until after eight weeks or 
more. It is probable that he could have walked immediately after the 
reduction, without much if any inconvenience, so trivial was the inflam- 
mation which resulted from the accident. He never complained of pain, 
but only of a slight soreness back of the trochanter major, near the head 
of the bone. This soreness continued several weeks, and was especially 
present when he bent forwards. After the lapse of four months, when I 
last saw him, he occasionally felt a pain at this point in stooping, but the 
motions of the joint were free; he walked rapidly and without halt. 

Perhaps in most cases, and especially when the head of the bone has 
not been carried by consecutive displacement upwards until it rests fairly 
upon the lower portion of the dorsum ilii, the most important step in the 
manoeuvre is to lift the bone toward the socket, by placing the arm 
under the knee (the patient resting upon his back) and drawing directly 
upwards. 

Prof. Gunn, describing his method, says : An assistant fixes the pelvis 
while the surgeon flexes the thigh at a right angle with the trunk, and 
the leg upon the thigh ; he then adducts, rotates inwardly, and draws 
the limb forwards in the direction of extreme adduction, thus lifting the 
head directly into the socket. Essentially Prof. Bigelow adopts the 
same method. 

If the reduction is attempted by extension, we ought to remember 
that the head of the bone lies more behind than above the Bocket, and 
that it is not requisite to carry it downwards so much as forwards ; and 
especially that it must mount over the mosl elevated margin of the 
socket, in order to resume its position. The extension ought, therefore, 
to be mad _i:i angle with the body, as the following case will 

illustrate : 

John Hebden, set. 40, was - i r t i ? j lt with hi- lege hanging over the dock, 
when hi- left knee was struck by ;i ferry-boat, dislocating the head <»f* 
the femur into the ischiatic notch. I found him at Bellevue Hospital on 
the following morning, about twenty hours after the accident, September 
29, l^''.'i. In the recumbent posture the Limb was pretty Btrongly ad- 
ducted and slightly rotated inwards. It was shortened three-quarters of 
an inch. In the erect posture both adduction and inward rotation were 
-light. 

Having etherized him, I made three separate attempt- at reduction by 



848 DISLOCATIONS OF THE THIGH. 

manipulation, but failed. I then made extension in the following 
manner: The patient resting upon his back, [ stood astride his body, 
and clasping my bands under the knee, I pulled directly upwards, while 
an assistant held down the pelvis. I did not feel the bone resume its 
place, nor was I aware that reduction was accomplished, but when I let 
the limb down the bone was found to be in its socket. 

Two or three minutes later, and before the patient had recovered 
from the effects of the ether, I raised the knee, to indicate to some' 
young men. who had just come in, how the dislocation had been reduced,. 

Fig. 343. 




Reduction of dislocation upwards and backwards into the great ischiatic notch, by extension. 
(Sir Astley Cooper's Method.) 

when it Blipped out again, with a sudden jerk and a grating sensation, 
This sensation I had felt once or twice before while manipulating. It 
J* 8 scarcely as rough as the crepitus of a fracture, and it probably in- 
dicated that tin- cartilaginous margin of the acetabulum had been 
broken off. 

'I'll.- limb was now brought down to the bed, and it was found to be 
in the same position as before reduction was attempted. Standing 
again ov.-r the patient, and placing my hands under the knee, I pulled 
upwards, and tin- head resumed its place; this time with a sudden jerk 
and with the same rough sensation. The limb was then placed in the 
extended position and secured by a long splint, which was not removed 
until the eleventh day. 

facility with which the redislocation took place in the preceding 



INTO THE FORA11EX THYROIDEUM. 849 

case will sufficiently explain what happened in the following case on the 
tenth day after reduction, and on account of which I was subsequently 
consulted : 

William Milne, aet. IS. of Orleans County. X. Y.. was thrown from 
a wagon May 13. 1858, dislocating his left femur into the ischiatic 
notch. Dr. Watson, of Clarendon. Orleans County, was consulted within 
three hours. Drs. Wood and Tafft were also present. Dr. Watson 
laid the patient on his back, and without anaesthetics reduced the dislo- 
cation by manipulation. The bone was felt distinctly as it slipped into its 
place, and the limb immediately resumed its natural position and length, 
as all the surgeons present affirm. He was soon out of the house on 
crutches, and on the eleventh day went in bathing. When he came out 
of the water he complained of his hip, and on the following day it was 
seen to be shortened. Subsequently it was examined by several sur- 
geons, all of whom pronounced it dislocated. An attempt was then made 
to reduce the dislocation by Jarvis's adjuster, but without anaesthesia, as 
the patient refused to be rendered insensible. The attempt did not 
succeed, and the father brought an action against Dr. Watson in the 
Supreme Court of Orleans County, Judge Noah Davis presiding, for 
September, 1858. The prosecutor failed to appear, and Dr. Watson. 
the defendant, took judgment by default. 

Lente relates a case in which, extension being employed, the cord was 
suddenly cut Avhile the limb was abducted and rotated outwards, when 
the head of the femur left the ischiatic notch, and rose upon the dorsum 
ilii, assuming a position directly above the acetabulum, and below the 
anterior superior spinous process : and from which position it was subse- 
quently, with great difficulty, returned to the socket. 1 

£ 3. Dislocations Downwards and Forwards into the Foramen Thyroideum. 

Syn.— i: Downwards into the foramen ovale ; " Sir A. Cooper. (; Downward- into 
the obturator foramen ; " Lizars. " Downwards and forwards into the foramen obtu- 
ratorium : " B. Cooper. "Inwards and downwards into the oval hole;" Chelius. 
" Downwards and forwards into the foramen ovale : " Pirrie. " Downwards and in- 
wards;*' Boyer. "Subpubic;"' Gerdy. '• Ischio-pubic; : ' Malgaigne. 

Causes. — In order to produce this dislocation the limb must be. at 
the moment of the receipt of the injury, in a position of abduction. 
Perhaps most often it is occasioned by the fall of a heavy weight upon 
the back of the pelvis when the body is bent and the thighs spread 
asunder. 

Pathological Anatomy. — The capsule gives away upon the inner Bide 
'ally: the round ligament is torn from its attachment, and the 
head of the femur, pressing forwards and downwards, finds ;i Lodgement 
upon or against the obturator externus muscle, over the foramen thy- 
roideum. 

Symptoms. — The thigh is apparently lengthened from one to two 
inches, abducted and flexed, the body being also bent forward- or flexed 
upon the thigh, 'fin- dislocated limb is advanced before tie- other, and 
the * illy point directly forward-, but they may incline either 

Lente, New York Journ. lied., November, 1850, p. 814. 

■ I 



850 



DISLOCATIONS OF THE THIGH. 



mtwards or inwards. The liip is flattened or depressed; the long 
adductors are felt tense upon the inside of the limb; the trochanter 
major is less prominenl than upon the opposite side; and the head of 
the bone may sometimes be felt in its new position. The apparent 
lengthening of the limb alone is sufficient to distinguish this accident 
from a fracture of the neck. 



Pig. 344 



Fig. 345. 




■ n- of the' ilio-femoral ligament to the 
thyroid dislocation. (From Bigelow.) 



Dislocation downwards and forwards into 
the foramen thyroideum. 



I have said "apparent" lengthening, because in the position in which 
the limb is found, it is difficult to make an accurate relative measurement 
of the two limbs; and, indeed, Rivington, 1 of the London Hospital, could 
not in a case seen by him recognize any shortening, and in his experi- 
ments upon the cadavei he obtained a similar result. Holmes, 2 also, in 

1 Rivington, The Lancet, 1878, vol. ii. p. 321. 
: Holmes, Med. Times and Gaz., Oct. 27, 1877. 



INTO THE FORAMEN THYROIDEUM. 



851 



a clinical lecture has stated that the lengthening is less marked in propor- 
tion as the abduction and outward rotation are greater. 

In some cases the position of the head of the femur may be recognized 
by a rectal examination; or, in the case of females by a vaginal exami- 
nation. 

The flexion and abduction are due in some measure to the tension of 
the psoas magnus and iliacus interims, and perhaps to a similar condition 
of other rotators and flexors ; but, according to Bigelow, the ilio-femoral 
ligament offers the chief resistance, and constitutes the chief impediment 
to the restoration of the bone. 

W. Taylor 1 has reported an example of compound dislocation upon 
the foramen ovale, in which reduction having been effected, it was, sev- 
eral weeks after the accident, followed by an abscess ; but from which he 
eventually recovered with a tolerably useful limb, but not without some 
anchylosis. 



Fig. 346. 



Fig. 347 




Tense, untorn, upward and back- 
ward portion of capsular ligament in 
thyroid dislocation. (Gunn.) 



Illustrating what would be the degree of flexion 
in thyroid dislocation if the ilio-femoral portion of 
capsule remained untorn. (Gunn.) 



8 tya Prof. Gunn : "In the dislocation downwards and forwards over 

the thyroid foramen, the anterior and inferior portion of the capsular 
ligament must be torn asunder for the escape of the head; while from 
the extremelv abducted Mate of the limb at the moment of* the accident, 



lor, The Lancet, 18*1, vol. i. p. 782. 



852 DISLOCATIONS OF THE THIGH. 

the Buperior and posterior portion must be relaxed, and thus escape 
laceration. 

•• Fig. 346 illustrates this dislocation and the condition of the liga- 
ment It is seen that while the head of the femur occupies a position 
over the thyroid foramen, and while the characteristic deformity of 
direction in the limh is present, viz., a moderately flexed and slightly 
abducted position, the superior and posterior untorn portion of the liga- 
ment is tense and holds the limb in its state of slight abduction. The 
flexed position of the limb is due mainly to the necessarily tense condi- 
tion of the psoas magnus and iliacus muscles. 

•• The characteristic position of the limb in this dislocation is incon- 
sistent with the integrity of the ilio-femoral portion of the capsular 
ligament. The greatly increased distance between the anterior inferior 
spinous process of the ilium and the anterior inter-trochanteric line of 
the femur cannot be accommodated by anything less than the rupture of 
this portion of the ligament. The head of the femur can be placed over 
the thyroid foramen in the intact state of this portion of the ligament; 
hut in order to accomplish this, the femur must be flexed to a right angle 
with the longitude of the trunk. This is illustrated in Fig. 347. 

*■ An examination of this figure, or of the specimen wdiich I herewith 
exhibit, will fully warrant the positive statement, that in the downward 
and forward dislocation, if the limb is found in the position generally 
characteristic of this form of the accident, the only untorn part of the 
capsule will be the upward and backward portion, as is illustrated in 
Fig. 346." 

'/'■•• atment. — It is pretty certain that in the following example there 
was a spontaneous reduction, or rather, I ought to say, an accidental re- 
duction of a dislocated femur from the thyroid foramen. Perhaps it 
was "lily an example of a partial dislocation; of which species of for- 
ward dislocation I shall hereafter relate another case as having come 
under my own notice. 

Jacob Lower, ret. 10, fell from a tree, a height of about tw r elve feet, 
to the ground. It is not known how he struck. He became immedi- 
ately quite faint, and when he had partly recovered, he attempted to 
gel up. but could not. He said his leg was broken, and cried out lustily 
whenever it was moved. The father arrived in about an hour, and found 
him -till lying on his back where he had fallen, with his right leg car- 
ried away from the other, and turned outwards. He lifted him up to 
place him in a small hand-wagon, which was long enough for his body, 
but only one foot and a half in width. Finding that his right leg was 
BO much abducted a- to prevent his being laid in so narrow a space, he 
I upon it. and with some force pressed the knee inwards across the 
opposite leg, when Buddenly it resumed its position with aloud snap like 
a "cannon." 1 use the language of the father. On the following day 
mined the limb carefully, and found its motion free. He was, how- 
ever, romiting the contents of his stomach, and passing blood from the 
bladder quite freely. The vomiting soon ceased, but the haemorrhage 
from the bladder continued three or four days. On the ninth day he 
walked out. and on the twelfth he was seen climbing upon the top of a 
. I -aw him again after the lapse of a year, and found that he 



INTO THE FORAMEN THYROIDEUM. 853 

was still complaining of an occasional soreness in the region of the hip- 
joint. 

If we attempt to reduce by manipulation, it will be proper to follow 
the same rule which I have stated as applicable to dislocations back- 
wards, namely, to carry the limb, in the first instance, only in those 
directions in which it is found to move easily. Instead, therefore, of 
holding the leg in a position of adduction while the thigh is flexed upon 
the abdomen, it will be necessary to carry it up abducted ; and when 
the further progress of the knee toward the belly is arrested, the limb 
must be moved inwards, and finally brought down adducted. When the 
knee is about opposite the pubes, or a little lower, in its descent, the 
femur should be gently rotated inwards, for the purpose of directing the 
head toward the acetabulum, The reduction may also be sometimes 
facilitated by lifting the head of the bone with the aid of a band passed 
under the upper portion of the thigh and over the shoulder of an assist- 
ant ; by giving to the shaft of the femur a slight rocking motion when it 
is about to enter the socket ; by pressing with the hand against the head 
of the bone, and by lifting at the knee. 

Prof. Gunn proposes, also, to reduce this dislocation by lifting the 
head into its socket, while the thigh is at a right angle with the body, 
and in a position of forced abduction. 

In one of the examples recorded by Markoe (Case 8), the reduction 
was accomplished in the second attempt, by rotating the thigh inwards 
just as the thigh had descended below a right angle with the body, in the 
manner which I have above directed ; but in the second example (Case 9), 
a similar manoeuvre carried the head across into the ischiatic notch, while 
the reduction was finally accomplished by rotating the thigh outwards, 
and at the same moment adducting the limb strongly in a direction which 
carried the knee behind the other one. Markoe concludes that the latter 
mode is preferable, because it will throw the head of the bone a little 
upwards as well as outwards ; in which direction it will find a more gently 
inclined plane toward the socket. He admits, however, that both methods 
may accomplish the same result. But I am quite certain that the method 
by rotation of the shaft of the femur inwards is in general most likely 
to succeed. In this way also, I think, both W. H. Van Buren, of Now 
York. 1 and R. L. Brodie, of the U. S. Army, were successful; 2 it is the 
method preferred by Bigelow, who also recognizes the propriety of making 
outward rotation when inward rotation fails. "Flex the limb toward a 
perpendicular, and abduct it a little to disengage the head of the bone; 
then rotate the thigh strongly inward.-, adducting, and carrying the knee 
to the floor." It is especially worthy of notice that Anderson, so long 
- 177± in the case already quoted when T was considering the 
history of reduction by manipulation, practised successfully almosl pre- 
the same method. In one example mentioned by Markoe (Case 
7), it i- pretty evident that the head of the femur was thrown into the 

ischiatic notch, by having flexed the thigh too much, 80 that ••the knee 

1 W. IT. Van Buren, S [ed. Times, Jan. 1856, p. 127. 

2 B. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 93; from Charleston Med. 

Rev. 



854 



DISLOCATIONS OF THE THIGH. 



touched the thorax." Indeed, it is questionable whether it will be best 
ever to bring the thigh much, if at all, above a right angle with the body, 
since any further flexion can only throw the head below the acetabulum, 
when in fart it is already too low. 

Fig. 348. 




Reduction of thyroid dislocation by manipulation. (From Bigelow.) 

July 21, 1858, Nathaniel Smith, a painter by trade, aet. 33, fell from 
the second-story window of the city post-office, Buffalo, upon a stone 
pavement, striking, as he believes, upon the inside of his right knee. I 
saw lmii within an hour, and found the right tibia partially dislocated 
mit winds, the corresponding patella dislocated completely outwards, and 
the right fern id- in the foramen thyroideum. His thigh was forcibly ab- 
ducted, slightly rotated outwards, and lengthened, by measurement made 
from the pelvis to the ankle, one inch and a half. The distance from 
the anterior superior spinous process to the fold of the groin was ten 
inches, but upon the sound side it was only eight and a half. The head 
of the femur could be distinctly felt in front, just under the pubes. 

Having administered chloroform, I first reduced the tibia and the 
patella, then Beizing the thigh and leg, I flexed the thigh upon the body, 
carrying the limb upwards abducted until it was nearly or quite at a right 
angle with the body, then inclining the knee slightly inwards, I brought 
it down again, and when the thigh had nearly reached the bed, it fell 
into it- sockel with a dull flapping sensation. In every step of the pro- 
cedure I followed the inclination of the limb. The recovery was rapid 
and complete. 

Sii- Astley hooper says that this dislocation is in general reduced very 



IXTO THE FORAMEN THYROIDEUM. 



855 



easily by the aid of pulleys : at least if the accident is recent. He 
advises that the patient shall be placed upon his back, with his thighs 
separated as far as possible. The pulleys are to be made last to a band 



Fig. 349. 




Sir Astley Cooper's mode of reducing a recent dislocation into the foramen thyroideum. 

drawn across the perineum of the dislocated limb, in a direction up- 
wards and outwards ; while a counter-band is to be passed around the 
pelvis through the band attached to the pulleys, and secured to a staple, 
or delivered to assistants placed upon the sound side of the body. When 
everything is arranged, the pulleys should be acted upon until the head 
of the femur is felt moving from the foramen thyroideum ; at this moment 
the surgeon must pass his hand behind the sound limb, and seizing upon 
the ankle of the dislocated limb, adduct it forcibly, thus converting the 
limb into a lever of the first order. 

If the dislocation has existed some time, he recommends that this pro- 
cedure shall be varied by placing the patient upon his sound <i<lc instead 
of his back, and attaching the pulleys perpendicularly <>y<t tin- body. 
Sir Astley especially cautions us not to flex the thigh during these 
manoeuvre-, lest we force the head of the bone backwards into the 
ischiatic notch, whence he affirms that it cannot afterwards be returned 
to its socket; but the experience of surgeons has since shown thai this 
latter statement i- incorrect, and thai it may, in some cases, be after- 
wards reduced, although it has fallen into the ischiatic notch. Mr. 
Liston says thai this accident happened to himself while attempting to 
reduce a dislocation of only a few hours' standing, in ;> young and pow- 
erful man, but Ik- had no difficulty in returning it to it- firsl position. 1 

1 Practical Surg., Amer. ed., p. 98. 



856 DISLOCATIONS OF THE THIGH. 

Brainard, of Chicago, reduced a dislocation of that form of which I 
am now speaking, after both the compound pulleys and Jarvis's adjuster 
had failed, by placing between the thighs a piece of wood wrapped about 
with Beveral layers of a wadded quilt, and making use of this as a ful- 
crum upon which the thigh operated as a lever. The legs were simply 
pressed together, care being taken to keep the knees straight. 1 

The majority of surgeons of the present day place the limb in the 
flexed position before attempting to make traction. This may be done 
with the patient lying upon his back, and by the hands, alone or with 
pulleys, or the patient may be placed in a sitting posture, and the exten- 
sion made at right angles with the body. In all of these attempts 
to reduce by traction, measures must be taken to secure immobility to 
the pelvis. 

May 23, 1868, a man, 40 years of age, was admitted to Bellevue, 
haying a dislocation of the left femur into the foramen thyroideum, 

Fig. 350. 




Effect of flexion upon the ilio-femoral ligament in the thyroid dislocation. (Prom Bigelow.) 

which had been caused six hours before by the fall of a heavy weight 
upon his back while stooping. The limb was slightly abducted, and 
moderately flexed upon the pelvis, while he was lying upon the bed; the 
position being that represented in Fig. 345. There was a very marked 
depression in the situation of the trochanter major, and a fulness upon 
the inside of the limb, caused by the tension of the long adductors. 

The patient being under the influence of ether, the house surgeon, 
Dr. E. I). Hudson, first attempted, under my instruction, to reduce the 
dislocation by manipulation, flexion, and rotation, with adduction; but 
failing in this, a folded sheet was placed in the perineum corresponding 
to the dislocated limb, and committed to assistants, who were directed to 

1 Brainard, Northwestern Med. and Surg. Journ., 1852. 



UPWARDS AND FORWARDS UPON THE PUBES. 



857 



pull upwards and outwards, the patient lying upon his right side, with 
his left thigh flexed to a right angle with his body. Dr. Hudson then 
passed a band under the upper part of the thigh and over his shoulders, 
lifting and pressing the knee forcibly inwards at the same time. In a 
few seconds the reduction was accomplished. 

After the reduction is accomplished, the patient should be laid upon 
his back in bed, but instead of rotating the limb outwards, as I have 
advised after a dislocation upon the dorsum ilii or into the ischiatic 
notch, it should be gently rotated inwards, and the knees thus bound 
together. 

§ 4. Dislocations Upwards and Forwards upon the Pubes. 

Syn. — "Upwards and forwards on the horizontal branch of the share-bone;" 
Chelius. ;: Forwards upon the pubes;*' Pirrie. " On the body of the pubes, below 
the spine and transverse part of the bone;" Skey. "Sur-pubic;" Gerdy. "Ilio- 
pubic:'' Malgaigne. 

Causes. — This accident is generally occasioned by a fall upon the foot 
when the leg is thrown backwards behind the centre of gravity ; as in a 
fall from the back end of a wagon, the foot being instinctively thrown 
backwards in order to save the head ; or it may happen to a person who, 
while walking, suddenly puts one foot into a hole, in consequence of 

Fig. 351. 




Specimen of dislocation upon the pubes, in St. Thomas's Hospital. (From Sir A. Cooper.) 

which the pelvis advances, but the leg and upper pari of the body incline 
forcibly backwards. Occasionally it has resulted from n fall upon the 
back of the pelvis, or from a severe blow received upon the same part. 
A patient was admitted, under tie- care of Dr. Ore, into St. Mary's 
Hospital, London, with ;< dislocation upon the pubes occasioned by swim- 
ming. His account of it was, thai when in the act of " striking oul he 
felt a catch in the right groin which he thought was cramp, and thai he 



858 



DISLOCATIONS OF THE THIGH. 



Fig. 352. 



waa able to walk after the accident, but with a good deal of difficulty. 
The examination proved thai he had a dislocation upon the pubes, which 
Dr. CJre easily reduced. 1 

Pathological Anatomy. — Sir Astley Cooper dissected the hip of a 
person whose thigh had been dislocated upon the pubes for some time, 
the true nature of the accident not having been at first recognized. The 
acetabulum was partly filled by bone, and partly occupied by the tro- 
chanter major, both of which were much altered in their form. The 
capsular ligament was extensively torn, and the ligamentum teres broken 
oft* completely. The head and neck of the femur had torn up Poupart's 
ligament, bo as to penetrate between it and the pubes, and lay under- 
neath the iliacus interims and psoas muscles; the anterior crural nerve 
was lying upon these muscles, over the neck of the femur. The head 

and neck were flattened and other- 
wise much changed in form. Upon 
the pubes a socket was formed for 
the neck of the thigh-bone, the 
head being above the level of the 
pubes. The femoral artery and 
vein were to the inner side. The 
specimen is still preserved in St. 
Thomas's Hospital (Fig. 351). 

The head of the femur may be 
found lying far forwards upon the 
pubes, as in Physick's case men- 
tioned below ; or it may lie farther 
back, along the ilio-pubic margin, 
and rest below and in front of the 
anterior superior spinous process 
of the ilium. When the head 
rests directly below this process, 
the dislocation is considered anom- 
alous or irregular, and this form 
will be considered hereafter as the 
"subspinous" dislocation. 

In the accompanying drawing 

the relation of the ilio-femoral 

ligament to the head and neck of 

the femur is shown, when the 

head ascends moderately upon the 

pubes. The extreme displacement 

shown in the preceding illustration 

from Sir Astley Cooper is only 

possible where that portion of the 

capsule beneath the obturator internus is torn, and perhaps the obturator 

itself. According to Bigelow, the ilio-femoral ligament and the psoas 

magnus and iliacus internus are then the only remaining causes of 




Dislocation upon the pubes below the ante- 
rior inferior spinous process of the ilium, 
. Bigelow.) 



; Medical News and Library, vol. 



, p. 1, from Lond. Lancet, Nov. 7, 1857. 



UPWARDS AND FORWARDS UPOX THE PUBES. 



859 



As we have seen in the ease reported by Sir Astlev Cooper, the femoral 
artery and vein are usually found upon the inner side of the head, but 
occasionally these vessels are in front of, and sometimes external to. the 
head. 

In a case related by Goldsmith, of Louisville, 1 where the femoral artery 
was situated in front of the head, and the dislocation remaining unre- 
duced, at the end of two months a diffuse aneurism having formed, the 
primitive iliac was tied, and the patient died on the fifth day. The 
autopsy revealed an opening in the artery, through which the head of the 
bone had passed until it lay within the cavity of the aneurism. 

Kronlein 2 reports a case of tearing of the femoral vein, in a case in 
which the leg had been thrown so violently backwards that the heel 
touched the back of the shoulder. 

Says Prof. Gunn : The weakest part of the anterior and upper por- 
tion of the capsule is "where it is not reinforced by the ilio-femoral 



Fig. 



Fig. 354. 





External view of pubic dislocation. Pos- 
terior border of the great trochanter occu- 
pying the acetabulum, pressing before it the 
posterior untorn half of capsule. (Gunn.) 



Anterior view; showing continuity of 
structure between the ilio-femoral and in- 
ferior border of posterior half of capsular 
ligament. (Gunn.) 



fibres. Through this the head escapes and rests in fronl of the body of 
the pubis, the posterior surface of the neck resting on the edge of tin- 
bulum, and the posterior border of the great trochanter settling 
somewhat into the socket. The portion of the capsule which remains 
untorn is the whole of the posterior half, and that pari of the anterior 



1 Goldsmith, Amer. Joura. Med. Bci., July. I860, p. ::«'. 

2 Kronlein. Poinsot, "p. cit.. p. 1072. 



860 



DISLOCATIONS OF THE THIGH. 



Fig. 355. 



half covered and strengthened by the reinforcing ilio-femoral fibres. The 
posterior half is forced down into the acetabulum by the trochanter major, 
which encroaches upon that cavity." Being thus pressed into the acetab- 
ulum this portion becomes " moderately tense, but it does not exert much 
influence on this dislocation in any way. On the contrary, the ilio- 
femoral portion of the capsular ligament in front, with the posterior 
untorn portion from below the cervix, holds the dislocated head in its 
luxated position. In this dislocation, the ilio-femoral portion of the cap- 
sular ligament, by its continuity with the inferior border of the posterior 

untorn portion, possesses the potency 
which Professor Bigelow claims for it 
in all dislocations." 

Symptoms. — The thigh is shortened 
sometimes, but not always, abducted, 
flexed slightly, rarely extended, and 
rotated outwards. The trochanter 
major is carried back and lost, or nearly 
so, while the head of the bone may be 
generally felt like a round ball, lying 
upon or in front of the body of the 
pubes, in most cases outside of the 
femoral artery and vein. Larrey saw 
a patient in whom the femur was 
placed nearly at a right angle with the 
body ; and Physick once met with a 
dislocation upon the pubes "directly 
before the acetabulum," in which the 
limb was not at all shortened, but, on 
the contrary, a very little lengthened. 1 
Other surgeons have occasionally seen 
similar examples. 

The differential diagnosis between 
a fracture of the neck of the femur 
and this dislocation may be thus 
briefly stated. In the fracture there 
is crepitus, mobility, slight eversion 
easily overcome, no abduction, the 
trochanter major rotates on a short 
radius, and the head of the bone can- 
not be felt. In this dislocation there 
is no crepitus, the limb is immobile, 
the eversion is extreme and not easily 
overcome, the thigh is often abducted, 
the trochanter major rotates upon a 
longer radius, and the head of the 
ition upwards and forwards upon }>one can generally be distinctly felt 
the pubes. in its unnatural position. 




1 Dorsey's Surgery, vol. i. p. 238, 1813 



UPWARDS AND FORWARDS UPON THE PUBES. 861 

Prognosis. — Sir Astley Cooper remarks that although this accident is 
easv of detection, he has known three instances in which it was over- 
looked, and he cannot but regard such errors as evidence of great care- 
lessness on the part of the surgeon who is employed. 

The reduction has generally been accomplished, in recent cases, with 
no great difficulty; and when not reduced, the patients have occasionally 
recovered with very useful limbs. 

Treatment. — From the several reported examples of dislocation upon 
the pubes reduced by manipulation, it would be difficult to draw any 
practical conclusions, since the methods have differed so widely from 
each other. I shall mention only four, which may be found in our own 
journals. One of these has already been mentioned in connection with 
the history of this process, as a case of compound dislocation reduced by 
Dr. Ingalls, of Chelsea, Mass. ; and two examples were reported by E. J. 
Fountain, of Davenport, Iowa. Dr. Ingalls succeeded by carrying the 
limb into its greatest state of abduction, and rotating the thigh inwards : 
the replacement of the bone being aided also by pressing upon its head 
with his fingers thrust into the wound ; while Dr. Fountain succeeded 
equally in both of his cases, by an almost opposite mode of procedure, 
namely, by adducting the limb forcibly, rotating the thigh outwards, and 
then flexing the thigh upon the body. 

The first of Dr. Fountain's cases occurred in June, 1854. The 
patient, an adult male, had fallen from the second story of a house to 
the ground, fracturing his lower jaw, and dislocating his left hip. The 
limb was a trifle shortened, and the foot strongly everted. The promi- 
nence of the trochanter was lessened, and the head of the bone could 
be felt upon the pubes. Assisted by Dr. Arnold, he reduced the limb 
in the following manner: The patient w r as laid on the floor, and placed 
completely under the influence of chloroform. The dislocated limb was 
then ''seized by the foot and knee and rotated outwards, the leg flexed 
and carried over the opposite knee and thigh, the heel kept well up, and 
the knee pressed down. This motion was continued by carrying the 
thigh over the sound one as high as the upper part of the middle third, 
the foot being kept firmly elevated. Then the limb was carried directly 
upwards by elevating the knee, while the foot was held firm and steady, 
at the same time making gentle oscillations by the knee, when the head 
of the bone suddenly dropped into its socket/' 1 The time occupied was 
not more than thirty second-, and the force employed was very slight. 

The second case occurred on the 31st of October, is.";."), in the person 
of John McCarthy, an Irish laborer; the dislocation having been occa- 
sioned by falling with a horse, while riding. The reduction was effected 
in about twenty seconds by the same process, and without the aid of 
chloroform. 

Dr. Henry, of New York, successfully reduced a dislocation of the 
femur upon the pubes after twenty-six day-. Tie- firsl attempt, made 
October 23d, was unsuccessful. The second attempt was made October 
29th. After repeated trials, by forced abduction and circumduction the 
head of the bone was thrown into the thyroid foramen, after which by 

1 Fountain, New York Journ. Med., Jan. 1866, p. 69 • 






I'ISLOCATIONS OF THE THIGH. 



abduction and extension it was conveyed into tlie acetabulum. He was 
dismissed cured in about three months. ' 

It is probable that no one method will succeed equally well in all cases; 
but if the head of the bone, as in the ease dissected by Sir Astley Cooper, 
has not only actually surmounted the pubes, but pushed itself fairly into 
the pelvis, then the limb ought to be abducted in the manner practised 
by Lngalls, and forcibly rotated outwards, in order that the head may be 
thus lifted over the pubes ; and subsequently it should be flexed upon 
tin- body, adducted and brought down. But in this manoeuvre we ought 
to. be careful not to continue the rotation outwards after the head of the 
femur has risen above the pubes, lest the head and neck should grasp, 
as it were, the psoas magnus and iliacus interims muscles, underneath 
which they have been thrust. On the contrary, it will be necessary at 
this point to rotate the thigh again gently inwards, which, by compelling 
the head to hug the front of the pubes, will enable it, while the flexion 
ia being made, to slide downwards under these muscles toward the socket. 
If, however, the head of the bone has never risen upon the summit of 
the pubes, and is not actually engaged under the muscles which pass over 
it at this point, then the rotation outwards will not be necessary in any 
part of the procedure. 

Barron Larrey has reported a case of dislocation " before the hori- 
zontal portion of the pubes," which he reduced "by suddenly raising 
with his shoulder the lower extremity of the femur, while with both 
hands he depressed the head of the bone." 2 This is the same case of 
which I have already spoken as being attended with the unusual phenome- 
non of the thigh placed at a right angle with the body. 

Fig. 356. 




Reduction of dislocation upon the pubes, by extension. 

If reduction is attempted by extension, the patient ought to be laid 
on hi- hack upon a tabic, with the dislocated limb falling off slightly 
from it> side. The extending band, made fast above the knee, should 
then he secured to a staple in the line of the axis of the dislocated thigh, 



M H Henry, A.mer. Journ. Med. Sci., Jan. 1875. 
2 Larrey, Loud. Med.-Chir. Rev., Dec. 1820, p. 500; 
let in de \. .. 1. 



-ol. L, first series, from Bui- 



ANOMALOUS DISLOCATIONS. 863 

and of course below the table ; while the counter-extending band, cross- 
ing under the perineum, should be made fast in the same line, above the 
level of the table, and beyond the head of the patient. 

"When extension is commenced, and the head of the femur has begun 
to move, the reduction may sometimes be facilitated by lifting the upper 
part of the thigh with a jack-towel or a band passed under the thigh 
and over the neck of the surgeon, as I have recommended in both of 
the backward dislocations. It may be found advantageous also to flex 
and rotate the limb after extension has brought the head near the socket. 

*. 5. Anomalous or Irregular Dislocations, or Dislocations which do not 
properly belong" to either of the Four Principal Divisions before 
Described. 1 

(Bigelow regards as "irregular" only those in which there is a com- 
plete disruption of the ilio-femoral ligament.) 

1. Dislocations directly Upwards above the Margin of the Acetabulum, 
and beloiv the Anterior Inferior Sjnnous Process. 

Syn. — " Sus-cotyloidiennes;' ! Malgaigne. "Subspinous." " Sixth dislocation ;' ? 
Mutter. 

Malgaigne affirms that the head, in this dislocation, is situated external 
to the anterior inferior spinous process, and about one inch below the 
anterior superior spinous process. 

It is in this position that the head of the femur is found in a specimen 
deposited in the Museum of the Surgical Clinic of Bonn, by Kroniein. 
A new cotyloid cavity exists posterior to and on a level with the anterior 
inferior spinous process. 2 

Blasius, of Halle, 3 says he has been able to reproduce this dislocation 
upon the cadaver by forced extension (dorsal flexion), combined with 
adduction and outward rotation. 

The symptoms which characterize this accident are shortening of the 
limb, slight abduction and extension, with rotation outwards. The ever- 
sion of the toes, together with the slight amount of shortening which has 
in general been observed, has led several times to the supposition that it 
was a fracture of the neck of the femur; but the rigidity, and the posi- 
tion of the trochanter and head will usually render the diagnosis clear. 

The following was probably an example of the subspinous dislocation : 

Bennett Morris, let. 51, was thrown backwards, in wrestling, in 1851. 

1 Malgaigne, Trait/'- des Frac. et dea Lux., torn. ii. p. 869 et seq. Samuel Cooper, 
First Lines, vol. ii. p. 391. Pirrie'a Surg., Amer. ed., L852, p. 275. Skey's Surg., 
Amer. ed., L851, p. 110 el -<■<). Gibson's Surg., sixth American ed., vol. i. p. 886. 
Guy's Bospital Reports, 1836, vol. i. pp. 79 and f .n ; 1888, vol. ill. p. 168. London 
Lancet, Lond. ed., 1848, vol. i. p. 1*4; 1840, vol. ii. p. 281 ; L846, vol. i. p. 412 j vol. 
ii. p. 169. London Med. Gaz.,vol. xix. pp. 657 and 659; vol. x. p. L9; vol. jcxxiii. 
p. 404. Med.-Chir. Trans., vol. xx. p. ill'. Lente'e paper on "Anomalous Di 
tions of the Hip-joint, ".in New. York Journ. Med. for Nov. I860, p. 814 et seq. Phil- 
adelphia Med. Examiner, No. 51. Amer. Journ. Mel. Sci., vol. xvi. p. 11. New 
York Med. and Phys. Journ., 1826, vol. v. p 697. Ne* STork Journ. Med., Jan. 
1860, Dr. Shrady's ease. Dislocation of the Hip, by Jacob J. Bigelow, M.D., 1869. 

2 Kroniein, Poinsot, op cit.,p. 1076. 

3 Blasius, Archiv fur Klin. Chir., Bd. 16, lift. 1. p. 207. 



864 DISLOCATIONS OF THE THIGH. 

He Pelt a snap in the hip-joint, and found his thigh placed in a position 
of moderate abduction, so that he could not get his knees together. 
He was able to walk, but not -without limping. This condition continued 
three years, during which time he was constantly lame, and suffered 
much pain when walking. 

At the end oi' this period, when in the act of jumping from his wagon, 
his horses having become frightened, he felt a snap, and at once the 
complete functions of the joint were restored. He could walk without 

Fig. 357. 




Subspinous dislocation. Kronlein's specimen. 

pain or halt, and lie could bring his knees together. Three months 
later, while ascending a flight of steps, carrying a heavy weight, his 
fool -lipped, and the dislocation was reproduced, and in this condition it 
remained lip to the period at which he consulted me, October, 1869. I 
found the thigh apparently elongated, but upon measurement it was 
found shortened half an inch. It was moderately abducted and rotated 
outwards. All the motions of the joint were restricted. 

Although I felt very confident that the reduction could be again ac- 
complished, the patient left without permitting me to make the attempt. 

hit lick Coleman, ret. 52, was admitted to Bellevue Hospital, Dec. 31, 
1875, with a dislocation of the right femur upwards. He had fallen 
nine feet into a cellar. Dr. Erskine Mason, in whose ward the patient 
was received, called my attention to him a few hours after the injury 
was received. The Limb was shortened one-fourth of an inch, as nearly 
as we could ascertain; strongly everted, or rotated outwards, but hang- 
ing parallel with the other when lie was standing, the right foot being a 



ANOMALOUS DISLOCATIONS. 865 

little in advance of the left. The head of the bone could be seen and 
felt below and to the inside of the anterior superior spinous process. 
The trochanter major was turned back, and there was a deep depression 
over it. The limb could be slightly adducted, but in all other directions 
it was immovable. 

After several ineffectual attempts at reduction, under ether, it was 
finally reduced by simple extension. 

March 27, 1877. Michael Monroe, set. 62, was admitted into the New 
York City Hospital with a dislocation of the left femur upwards and for- 
wards upon the ilium. Dr. Charles M. Allin, one of the visiting sur- 
geons, made some efforts at reduction on the same day, but failed. On 
the following day. in the presence of several medical gentlemen, includ- 
ing myself. Dr. Allin repeated his efforts more systematically, and was 
successful. 

Examining the limb while the patient was on his back, and under the 
influence of ether, preparatory to the operation, I found it shortened 
half an inch, strongly everted, and the thigh slightly flexed, but lying 
nearly parallel with the other. The thigh could be adducted quite 
freely, but in all other directions motion was more limited. With some 
difficulty it could be flexed to a right angle with the body. The head 
could be distinctly felt, but hot seen, directly below the anterior superior 
spinous process ; and from this position it was occasionally moved, while 
manipulating, farther forwards, but never fairly upon the pubes. The 
patient was a spare man. and not very muscular. 

The accident was caused by stumbling while ascending a flight of 
steps, and falling upon his knees and face. The skin over the spine of 
the tibia was much bruised and scratched. 

Dr. Allin made an attempt at reduction, 1st, by flexing the thigh at 
a right angle, and rotating outwards forcibly. This was unsuccessful. 
2d. By flexion and rotation inwards. 3d. By extension in several 
directions by the hands, including vertical extension, with the thigh 
flexed upon the body. 4. Compound pulleys were attached to a lacque 
above the knee, and counter-extension was made by a folded sheet 
passed under the perineum, and secured to a staple: the direction of 
extension being a little back from the line of the axis of the body, as 
recommended by Sir Astley Cooper. A jack-towel was placed under 
the upper part of the thigh, by which this part of the limb was lifted 
upwards and outwards : a folded sheet also being carried across the 
pelvis to render it steady. The extension was now gradually increased, 
and the limb was from time to time rotated, and otherwise manipu- 
lated, bo far a- its condition of restraint would permit, until it seemed 
probable that this method was to fail also, the patient haying uow 
been under the influence of ether nearly an hour. 5th. While the ex- 
tension was extreme, the cord was cul by a quick stroke "1" an ampu- 
tating-knife; and immediately after, while the limb was lying paralyzed 
by the "shock," Dr. Allin seized the thigh, raised the knee a little. 
rotating it inwards, when the head fell easily into it- socket. 1 

1 Brief report <■'. suprapubic " dislocation, in Archives <>f Clinical 

Sur-ery. April 15, : -~~ 



866 



1> FLOTATIONS OF THE THIGH. 



Other Burgeons have mel with examples of the subspinous dislocation 
in which the patients have been able to walk quite well immediately after 
tlif accident. Bigelow supposes that in these cases the upper portion of 
the capsule lias been completely torn from the margin of the acetabulum, 
and thai the bead lias been permitted to ascend until it was arrested by 
the under surface of the ilio-femoral ligament at the point where it rises 
from the anterior inferior spinous process of the ilium. 

-2. Dislocations directly Upwards, between the Anterior Inferior and 

Anterior Superior Spinous Processes. 

Syn. — "Supraspinous;" more appropriately, " Intraspinous." 

Cummins reports a case which occurred in the practice of Gibson, of 
New Lanark, where the head of the bone was believed to be situated just 
above the anterior inferior spinous process and below the anterior superior 
spinous process; and also a little inwards toward the pubes. The limb 
was shortened fully three inches ; the toes everted; adduction and abduc- 
tion were exceedingly painful and difficult, but flexion was more easily 
performed. The head of the bone could be felt in its new position, espe- 
cially when the thigh was moved. At first it was supposed to be a fracture, 
but this error having been corrected, the surgeons proceeded to attempt 
reduction on the eleventh day. Extension was made by pulleys, and when 

Fig. 358. 




Supraspinous dislocation. (From Bigelow.) 



the head of the bone had descended to the margin of the cavity, Mr. Gib- 
-.li lifted the upper end of the femur by means of a towel, at the same 
momenl pressing the knee toward the opposite thigh, and forcibly rotating 
th<- limb inwards; he which means the reduction was accomplished. 1 
Lente has Been the head of the femur in the same position as in the 

1 Oummins, Guy's Hospital Reports, vol. Hi. p. 163, 1838. 



ANOMALOUS DISLOCATIONS. 8*37 

case reported by Cummins, not as a primitive dislocation, but consequent 
upon an attempt to reduce a dislocation into the ischiatic notch. The 
shortening was about two inches ; the limb very much rotated outwards ; 
the rotundity of the affected hip greater than that of the other, and the tro- 
chanter major one inch farther removed from the anterior superior spinous 
process. The head of the bone could be felt distinctly in its new position. 

The reduction was effected finally with pulleys, by the aid of chloro- 
form, and by rotation of the limb in various directions. 1 

Morgan also reports a case in which the head of the femur was above 
the acetabulum, and a little to the outside of the ilio-pectineal eminence. 2 

Some of these dislocations have been reduced by manipulation alone, 
or by manipulation aided by pressure. The limb should be seized in 
the usual manner, at the knee and ankle, carried up toward the face, 
abducted, then rotated inwards, gently adducted, and finally brought 
down again to the bed. At the moment when the rotation and adduction 
commence, the head of the bone should be pressed toward the socket by 
the hands, and, if necessary, lifted a little over the margin of the ace- 
tabulum, by moderate extension at a right angle with the body. Others 
have been reduced easily by extension alone after a thorough trial of 
manipulation. 

Anterior Oblique Dislocations. 

3. Dislocations Upwards upon the Dorsum Ilii, and near its Anterior 

Margin. 
Syn. — "Anterior oblique ; : ' Bigelow. 

Bigelow, who, as has already been stated, regards as irregular only 
those which are accompanied with a complete rupture of the ilio-femoral 
ligament ; but whose classification in that regard I am not fully prepared 
to adopt; has nevertheless given us the most intelligible and most prob- 

Fig. 359. 




"Anterior oblique dislocation." (From Bigelow.) 

able explanation of the mechanism of these irregular upward dislocations) 
and of several other forms of irregular dislocations. According to tin- 
writer, the ••anterior oblique dislocation/' in which the limb is found greatly 

1 Lento, New York Journ. of Med., \--v. I860, p. -°>14. 

2 Pirrie's .Surgery, p. 276. 9 P M< I ""■• No. 51, Muttor'a p;i|><:r. 






HSLOCATIONS OF THE THIGH. 



adducted, and at the same time strongly everted, is a regular dorsal dislo- 
cation, the head being advanced upon the dorsum to a point near the ante- 
rior margin of the ilium. If now the limb be brought down, the neck of 
the femur will be made to hear against the outer fibres of the ilio-femoral 
ligament, and as these gradually give way the head will become more and 
more hooked over the remaining fibres of the ligament, and above the 
inferior spinous process ("supraspinous"); or, continued efforts being 
made to straighten the limb, the ligament will give way entirely, and the 
femur will assume the position indicated by the dotted lines (Fig. 358). 

Bigelow recommends a plan of treatment essentially the same as that 
hitherto recommended by myself. " The anterior oblique dislocation 

Fig. 360. 




Mechanism of " anterior oblique dislocation." i^From Bigelow.) j 

may be reduced by inward circumduction of the extended limb across the 
symphysis, with a little eversion, if necessary, to disengage the head of 
the bone. Inward rotation then converts this into the common luxation 
upon the dorsum." 

4. Dislocations Downwards and Backwards upon the Posterior Part of 
the Body of the Ischium, between its Tuberosity and its Spine. 

James C, set. 35, was admitted to the Pennsylvania Hospital, on the 
23d of January, 1835, under the care of Dr. Hewson. The patient, 
a muscular man. had been crushed under a falling roof, and, as he 
thought, with liis right thigh separated from his body. When received 
into the hospital, one hour after the accident, the right thigh was flexed 
upon the pelvis, and rested upon the left; the right leg was also flexed 
npon the thigh : the knee was below its fellow, the toes turned inwards, 
and the whole limb shortened at least one inch. The head of the bone 
could be felt distinctly resting upon that portion of the ischium which 
lies between the acetabulum, the tuberosity of the ischium, and the spine. 

On the following day, the muscles of the patient having been suffi- 
ciently relaxed by suitable means, the pulleys were applied; but, after 



ANOMALOUS DISLOCATIONS. 869 

a second attempt, some of the bands having given way suddenly, the 
pulleys were removed, when it was found that the reduction had been 
accomplished, although neither the patient nor his attendants had 
noticed the return of the bone to its socket. For several days there 
was entire loss of sensibility and motion in the leg, owing probably to 
the pressure which had been made upon the sciatic nerve ; but these 
symptoms gradually disappeared, and at the time when the case was re- 
ported, about two months after the accident, he was walking with crutches. 

Dr. Kirkbride, who reported this unusual case of dislocation, doubted 
whether the extension was necessary to the reduction, as the head of 
the bone was brought very near the margin of the acetabulum by lifting 
the thigh with a towel, and it probably afterwards entered the socket as 
soon as the extension was relaxed. 1 

Malgaigne has referred to several similar examples. 

5. Dislocations Downwards and Backwards into the lesser or lower 
Ischiatic Notch. 

Syn. — ''Behind tuber ischii ; " Gibson, S. Cooper. " Fifth dislocation ; " Gibson. 

September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a 
spirited horse, when the animal, being restive, suddenly reared and 
fell back on his rider, in such a manner that the weight of the horse 
was received on the inside of the left thigh ; Mr. Lowell having fallen 
on his back, a little inclined to the left side. The surgeon who was 
immediately called, recognized it as a dislocation, and thought he had 
succeeded in reducing it ; but a day or two later it was seen by a second 
surgeon, who declared that it was still out of place, and repeated the 
attempt at reduction, but without success, as the result proved. 

In December of the same year Mr. Lowell called upon Dr. John C. 
Warren, of Boston, who was now able to determine, easily, as he 
affirms, the precise character of the accident. The limb was elongated, 
contracted, and the head could be felt in its unnatural position. By 
advice of Dr. Warren, he was taken to the Massachusetts General 
Hospital, and a persevering attempt was there made to reduce the bone, 
but with no better success than had attended the efforts previously made. 2 

Mr. Keate has reported a case produced in a very similiar way by 
a horse having fallen backwards with the rider into a deep and narrow 
ditch ; but the position of the limb was somewhat extraordinary, con- 
sidering that it was a dislocation backwards, the whole limb being 
very much abducted and the toes being turned outwards, as if the 
head of the bone was in front of the tuber ischii, rather than behind it. 
The thigh and 1<-L r were much flexed, and the whole limb was short- 
ened from three to three and a half inches. The head of the femur 
could be distinctly felt "inferior to the ischiatic notch, and on a level 
with the tuberosity of the ischium/' In the Brsl attempt a1 reduction the 
head of the bone was thrown into the foramen thyroideum, from which 

1 Kirkbride. Amer. Journ. Died. Bci., vol. xvi p. 13. 

- v fork Bled, and Phya. Journ., vol. v. p. 597, 1826. Letter to the Bon. I 
Parker, etc., by John C. Warn;.. 1826. North Amer. Med. Journ., vol. iii. |». 169. 



B70 PISLOCATIONS OF THE THIGH. 

it was, however, after one or two more attempts by extension, and by 
lifting with a jack-towel, restored to the socket. Mr. Keate believes 
that the dislocation was originally into the foramen ovale, but that in 
the struggles made by the patient to extricate himself, it was thrown 
backwards into the position in which he found it. 1 

Mr. Wormald has reported a primitive accident of the same kind, 
occasioned by jumping from a third-story window. The patient died 
soon after, and at the autopsy the head of the femur was found under 
the outer edge of the glutseus maximus, projecting through the torn 
capsule opposite the upper part of the tuber ischii. The shaft of the 
femur lay across the pubes, and the limb was considerably shortened and 
turned inwards. 2 

6. Dislocations directly Downwards. 
Syn. — " Sous-cotyloidiennes;" Malgaigne. 

The following is one of several similar examples now upon record : 
A man. Bet. 50, was admitted into the London Hospital under the 
care of Mr. Luke. A dislocation of the left femur was easily diagnos- 
ticated, but the symptoms were peculiar, inasmuch as the limb was 
lengthened one inch, without either inversion or eversion ; yet the 
head of the bone could be easily felt, and was thought to be in the 
ischiatic notch. By manipular movements reduction was easily effected 
about an hour after the accident. The man subsequently died from 
the effects of broken ribs. At the autopsy, Mr. Forbes, the house- 
surgeon, before dissecting the parts, again dislocated the bone. This 
was done with ease, and it was clear that the original form of disloca- 
tion had been reproduced, as the bone could not be made to assume 
anv other position. The head of the bone proved to be displaced neither 
into the ischiatic notch nor the thyroid hole, but midway between the 
two, immediately beneath the lower border of the acetabulum. The 
gemellus inferior and the quadratus femoris had been torn, the liga- 
mentum teres had been wholly detached, and there was a laceration in 
the lower part of the capsular ligament. 3 

Dr. Blackman, of Cincinnati, informs me that, in January, 1859, 
lie reduced a subcotyloid, incomplete dislocation, in a man set. 70, by 
manipulation, Dr. Judkins lifting the thigh upwards and outwards by 
means of a towel, while Dr. Blackman first flexed and then abducted 
the limb. 

7. Dislocations Forwards into the Perineum. 

— ; - Perineales;" Malgaigne. '-Luxation Bur la branche ascendante de l'is- 
chion;" D'Amblard. " Inwards on the ramus of the os pubis ;" Skey. 

D'Amblard published an example of this accident in 1821, occasioned 
by a violent muscular exertion made by the patient in an effort to spring 
into his carriage, the symptoms attending which did not differ materially 

r. Journ Med.Sci., vol.xvi.p. 226, 1835; from Lond. Med. Gaz., vol. x. p. 19. 
• Wormald, London Med. Gaz., 1836. 

1 Luke, Med. NTewa and Library, vol. xvi. p. 34, March, 1858; from Med. Times 
! 868. 



ANOMALOUS DISLOCATIONS. 871 

from those which were found to be present in the three following exam- 
ples, except that in the first case the toes were turned slightly inwards, 
while in each of the other cases they were turned outwards. 1 

Mr. E. set, 35, a calker by occupation. The injury was received 
while at work under the bottom of a canal-boat. July '20, 1831, the boat 
being raised upon props three and a half feet long. The patient was 
standing very much bent forwards, with his feet far apart, between which 
lay a piece of round timber one foot in diameter, when the props gave 
way. letting the whole weight of the boat upon himself and his com- 
panions. One of the workmen was killed outright. On extricating Mr. 
E. from his situation, the left: leg and thigh were found extended at a 
right angle with the body, the toes turned slightly inwards, the natural 
form of the nates was lost, and the head of the femur could be felt dis- 
tinctly moving, when the limb was rotated, in the perineum, behind the 
scrotum, and near the bulb of the urethra. 

For the purpose of reduction, the patient was laid on his back upon 
a table, and the pelvis made fast by a muslin band. Extension, accom- 
panied with moderate rotation, was then made in a direction outwards 
and downwards, bringing the head of the bone over the ascending ramus 
of the ischium, beyond which it was lying, into the foramen thyroideum ; 
and from this position the bone was replaced in the acetabulum, by car- 
rying the dislocated limb forcibly across the opposite one. The patient 
soon recovered the use of the joint. 2 

J. B.. an Irishman, aet. 40. on entering the St. Louis Hospital, gave 
the following account of his accident, which had occurred six hours pre- 
viously : He was engaged in excavating earth, and having undermined a 
bank, it unexpectedly fell upon his back while he was standing in a bent 
position, with his thighs stretched widely apart. The weight crushed 
him to the earth, breaking both bones of his right leg, the radius of the 
same side, and dislocating the left hip into the perineum. The thigh 
presented a peculiar appearance, being placed quite at a right angle with 
the body, but somewhat inclined forwards. The part of the hip naturally 
occupied by the trochanter major presented a depression dee]) enough to 
receive the clenched fist ; while the head of the bone could be both seen 
and felt projecting beneath the skin of the raphe in the perineum. Rota- 
tion of the limb, which was difficult and excessively painful, rendered 
the position of the head still more manifest. The patient had also reten- 
tion of urine, occasioned probably by the pressure of the femur upon the 
urethra. Having dressed the fractures, Dr. Pope placed the patient 
under the full influence of chloroform, and then proceeded to reduce the 
dislocated thigh : for which purpose "two Loops were applied, interlock- 
ing each other in the ,L r r<»in. and using the ]«-_: a- a lever, extension, by 
means of the pulleys, was made transversely t<» tin- axis of the body. A 
force was kept up for :i short time and the thigh-bone glided into 
it- socket witli a -nap tliat was heard by every attendant and patient in 
the large ward." 8 

1 M 

2 W.Parker, New York Ifed G Med., March, 
188 

3 Pope. St. Louis Med. and Surg. Journ., Jul ST. Journ. Med., M 
1852 



B72 DISLOCATIONS OF THE THIGH. 

A man, set. 22, was admitted to the Toronto Hospital, under the care 
of l>r. K. W. Hodder, January 15, 1855, having been injured by the 
fall of a bank of earth an hour before. The head of the right femur 
was found under the arch of the pubes, the neck resting upon the ascend- 
ing ramus. The thigh formed nearly a right angle with the body; be- 
in-- Btrongly abducted, and the toes were slightly everted. On the fol- 
lowing dav. the patient being placed under the influence of chloroform, 
extension and counter-extension were employed in the direction of the 
axis of the femur, that is, nearly at right angles with the body, while, 
at the same moment, the upper portion of the femur was lifted by a round 
towel. By this manoeuvre the head of the bone was carried into the 
foramen thyroideum. The force was now applied in a direction "more 
upwards and outwards; the ankle held by the assistant was drawn under 
the other and at the same time rotated." In a few minutes the com- 
plete reduction was accomplished. His recovery was steady, and three 
-weeks later lie was discharged, being able to walk very well with the aid 
of a cane. 1 

§ 6. Ancient Dislocations of the Femur. 

Says Sir Astley Cooper: "I am of opinion that three months after 
the accident for the shoulder, and eight weeks from the hip, may be fixed 
as the period at which it would be imprudent to attempt to make the re- 
duction, except in persons of extremely relaxed fibre or of advanced age. 
At the same time, I am fully aware that dislocations have been reduced 
at a more distant period than that which I have mentioned ; but in many 
ii stances the reduction has been attended with the evil results which I 
have just been deprecating." A remark which later surgeons do not 
seem always to have correctly understood, or which, if they have under- 
stood, they have not correctly represented; since it has many times been 
affirmed of this distinguished surgeon, that he regarded reduction of the 
hip as impossible after eight weeks, and they have proceeded to cite 
examples which would prove that he was in error. But long before Sir 
Astley's day, Gockelius mentioned a case of reduction of the femur after 
six months, and Giulio Saliceto declared that he had reduced a similar 
dislocation after one year, 2 and Sir Astley says that he is "fully 
aware " of the existence of such facts or statements ; yet with a knowl- 
edge of what has so frecjuently followed these attempts, he would not 
recommend the trial after eight weeks, except under the circumstances 
by liim stated : and notwithstanding the number of these reported suc- 
cesses has been considerably increased in our day, I suspect that Sir 
Astley's rule will continue to govern experienced and discreet surgeons. 
Certain examples which have recently been published of successful re- 
duction afro- six months by manipulation, if sufficiently verified, would 
encourage a hope that the period might be greatly extended, were it not 
that manipulation also has already failed many times in the case of 

1 Bodder, British Amer. Journ., Murch, 1861. 

2 Malgaigne, op. cit., torn. ii. p. 185; from Gallicinium Medico-practicum, TJlm, 

•.288. F ' 



ANCIENT DISLOCATIONS OF THE FEMUR. 873 

ancient dislocations, and that the attempt has sometimes been followed 
with disastrous results, even in recent cases. 

The following case was published in the first edition of this treatise. 
but I regret that I am now unable to say from what source my informa- 
tion was then obtained, and communications addressed by me to gentle- 
men in Havana have failed to trace the case to its original source. It 
will be observed, however, that there is no history of the accident which 
caused the dislocation, and its existence was not suspected until the 
patient arose after an illness which had confined him to his bed for a 
month or more. It was reduced without anaesthesia ; it was three or 
four times redislocated, notwithstanding the employment of judicious 
means to keep it in place, and while the patient was in bed ; that it was 
reduced with a snap. " deeper than is ordinarily observed in the reduc- 
tion of recent dislocations;" and, finally, when the patient was dismissed 
it is only said, he was able to walk without crutches. In short, a careful 
reading of the report must convey to the experienced surgeon a suspicion 
that it may not have been correctly diagnosticated, and that, if it was, 
its reduction may not have been thoroughly accomplished and perma- 
nently maintained. 

A Chinese boy. named Ah-sin, aged about sixteen years, arrived at 
Havana on the 4th of June, 1856, suffering from a severe illness, which 
confined him for a month or more to his bed, and the existence of the 
dislocation was not discovered until he had sufficiently recovered to rise 
upon his feet. It was then ascertained that he had a dislocation of the 
left femur upon the dorsum ilii. Upon inquiry. Dr. Martial Dupierris, 
of Havana, learned that the accident had occurred before leaving China, 
a period of more than six months. The boy was still feeble, the limb 
somewhat emaciated, and instead of being rigid from muscular contraction. 
all the muscles ''were in a flaccid condition, except the great gluteal, 
which was painful to the touch." Deeming the use of anesthetics im- 
proper, on account of the boy's feeble condition, these agents were not 
employed. Dr. Dupierris describes the method of reduction as follows: 
•• The body being held by two assistants by means of two bands, one of 
which passed beneath the perineum, and the other under the axillae. 
traction was made upon the limb by two strong and intelligent assistants, 
The movement of the head of the bone, resulting from this manoeuvre, 
was very limited, even when the force was much Increased : and the ex- 
cruciating pain, which the patient referred to the iliac region, compelled 
us for a moment to d 

•• The following day. the patient having obtained a tolerable aighl - 
rest by means of a narcotic potion, I concluded to attempt the reduction 
by flexion, believing that I could thus better prevent any accident which 
the necessary force might produce; the operator, in adopting this 
method, having it in his power to follow the head of the bone bypressure 
upon it with the hand, aiding it- movement in the proper direction, or 
Leviation that may occur. The emaciated condition of 
the boy was eminently favorable for such a procedure. 

•: The patient being placed upon his buck, and the trunk of the body 
made steady by assistants, with the left hand I grasped the upper part 
of the leg. placed the right hand upon the head of the bone in tin- iliac 



s74 DISLOCATIONS OF THE THIGH. 

fossa, and then proceeded to flex the leg upon the thigh, and the thigh 
upon the pelvis. By this movement the great gluteal muscle was re- 
laxed, and the head of the bone advanced, while with the right hand I 
directed the latter toward the cotyloid cavity. As soon as I judged the 
head to be immediately above the centre of the socket, I extended the 
leg, the thigh remaining flexed at a right angle; and then using the 
limb as a lever, I rotated it from within outwards, and at the same time 
extended it by making a movement of circumduction in a similar direc- 
tion. When, by these procedures, the limb was brought near to its 
opposite fellow, a snap audible to the assistants, and of a deeper charac- 
ter than is ordinarily observed in the reduction of recent dislocations, 
indicated the return of the head of the bone to its natural position; a 
tact which was further substantiated by the establishment of the original 
length and form of the member and the subsidence of the pain 

** The after-treatment consisted in placing a pad between the knees, 
and another between the internal malleoli, and confining the limbs to- 
gether by two bands, one above the knees, and the other around the 
lower part of the legs. But in spite of these precautions to prevent re- 
displacement, the next morning I found that the dislocation had been 
reproduced. It was again reduced, but for three successive days there 
was a redisplacement. After this, however, the head of the bone kept 
its place; passive motion was daily employed, and all suffering ceased. 
After twenty days of rest, and a liberal use of the lactate of iron, the 
patient was allowed to get up; and, being provided with a pair of 
crutches, upon which he exercised himself daily, improved very rapidly. 
The muscles gra dually recovered their bulk and vigor, and at the end of 
forty-eight days he was enabled to walk without crutches, although with 
some fear of falling. About the middle of August he was put to work 
in a cigar manufactory, and has continued well ever since." 

The case reported by Guyenot, of a young woman tw T enty-two years 
of age. in which Cabanis is said to have accomplished reduction after 
the dislocation had existed two years, was probably an example of chronic 
hip disease. Indeed. Malgaigne has placed it in this category, although 
by other writers, including Sir Astley, it has been spoken of as if it had 
been traumatic. It is said that the reduction was effected in 1768, but 
Gruyenot doc- not say that he was present when it was done, nor is there 
anything in the report of the case to render it certain that it was actually 
dislocated, or if dislocated that it was ever reduced. 1 

Nor la it proper to accept of the accidental reduction of the femur, 
reported to Sir Astley Cooper by Mr. Cornish, as a well-authenticated 
case, [ndeed, Sir Astley himself questions the accuracy of the report. 2 

Dr. Lewi- A. Sayre, in a paper read before the American Medical 
Association, has reported ;i case of pathological dislocation, into the ischi- 
al- notch, of nine months' standing, which he claims to have reduced, 3 
ami which T would nor deem it necessary to allude to in this place, ex- 
cept thai in commenting upon the opinions of others he seems to regard 

M n. de L'Acad&nie Royal <!<■ Chirurgie do Paris, torn, cinquieme, p. 803. 
Astley Cooper, Frac. and Dis , 2d Lond. ed., p. 101. 

Luxation of Femur into rsehiatic Notch, of nine months' standing, 
d by Manipulation, Trans. Amer. Med. Assoc.. 1866, p. 263. 



ANCIENT DISLOCATIONS OF THE FEMUR. 875 

it as a case of traumatic dislocation, although he does not specifically state 
that it was ; and that, having stated in his report that I was present, he 
has rendered it necessary that I should express my own views of the case 
and of the facts. 

The patient, Lieut. -Col. William A. Bullit, was wounded in battle, 
May 9. 1864, in two places, the first ball entering five inches below the 
anterior superior spinous process of the ilium, and remaining. He fell 
after the second shot, but he "rose immediately and walked half a mile 
to the rear."' Several attacks of erysipelas ensued, followed by abscess, 
one of which formed in the left iliac fossa. More than five months 
after the injury he, for the first time, turned from his back to his side, 
and in doing so he felt •• a slipping ?? of the caput femoris. This occurred 
almost daily for two weeks, when, dislocation being recognized, Dr. 
McDermott. assisted by Drs. Coolidge and Goldsmith, U. S. A., at- 
tempted to reduce it under ether, but failed. * ; In the latter part of 
February. 1865, four months after dislocation," another attempt was 
made to reduce it, under chloroform. The fact that this was not a trau- 
matic dislocation, dating from the period of the original injury, is thus 
confirmed by Dr. Sayre himself, for it was already more than nine 
months since he had been wounded, but the dislocation had taken place 
only four months previous. At this time the attempt at reduction was 
made by Professor Cook, assisted by Drs. Force, Cox, Gait, and Garvin, 
all of Louisville, Ky. This attempt failed also. July 20, 1865. Dr. 
Sayre. in the presence of several gentlemen, including myself, the 
patient being under chloroform, forcibly broke up some adhesions and 
brought the limb, which was flexed upon the pelvis, down to a position 
nearly but not quite parallel with the other, and there secured it with 
a weight and pulley. There was no claim at the time, so far as I know, 
that a restoration of the bone to its socket had been effected. Some 
months later I saw this gentleman standing with a high heel under the 
boot corresponding to the lame leg, and I was then informed by Dr. 
Sayre. in reply to my inquiry, that the dislocation was not reduced, but 
that, as I could see, the position of the limb was greatly improved. 

In Dr. Sayre's report of the case he does not state when the disloca- 
tion was reduced, and certainly it was not reduced in my presence: and 
I have no reason to suppose that it was subsequently. 

In closing his report Dr. Sayre take- exceptions to Dr. Gross- state- 
ment that "chronic" dislocations demand some preliminary treatment 
before attempting reduction to insure success, without noting the fact 
that the distinguished author was speaking then only of traumatic dis- 
locations, bur adding, in italics, "my belief is that the hot time to per- 
form such an operation i- when you find it necessary to be done.'" 

The editor of the Western Lancet, published in Cincinnati, mentions 
in a few line- ('vol. xvii. p. -2.',:). April, !>•"><;). that on tin- 22d of March 
preceding Dr. Blackman, a distinguished Burgeon of thai city, had re- 
duced, at tie- Commercial Hospital, a dislocation of tie- femur ppon the 
dorsum ilii, under chloroform, of -ix months 1 standing. No particulars, 
or authority for the statement, are given. Two months later tlii- editorial, 
or a copy of it. appeared in tie- Ohio Medical "ml Surgical Journal 
(vol. xviii. p. 522) without additional remarks or information. So far 



876 



DISLOCAl EONS OF Til E THIGH. 



as I know this is the only published account of the case. In reply to 
niv note of inquiry, addressed to Dr. Blackmail subsequently, he stated, 
April 21, L859, that the patient presented himself before the class 
"about six months since, and the restoration of the functions of the 
limb was found to be complete." Since the death of Dr. Blackman, 
hoping to obtain a more complete history of the case, I wrote to a gen- 
tleman in Cincinnati, who informed me that no farther history could be 
obtained, as the hospital record for that year was lost. 

Dr. George E. Post, Missionary in Syria, and a Professor in the 
Protestant College, at Beirut, has reported a remarkable case of disloca- 
tion of both hips in a native girl, thirteen years old, "the result of a 
vi% ,i tergo, applied six months previous " to her admission to the hospital. 
The force applied to her back caused her to fall forwards, with a " twist- 
in- of the trunk to the right, and the lower extremities to the left." 
She was admitted Jan. 20, 1877. At this time it was ascertained that 
she had a dislocation not only of the left femur, but that there was a 
fracture of the neck also on the same side; the head had become 
necrosed, and there was a sinus communicating with the head as it lay 
upon the dorsum ilii. An incision was made, and the dead bone was 
removed. The anchylosed knee and thigh w T ere then straightened by 
brisement force, the restoration being accompanied with a good deal of 
laceration. 

" The left lower extremity was then committed to an assistant, while 
the requisite manipulations were undertaken to reduce the dislocation of 
the right hip. This was effected without pulleys, adding another to the 
many proofs that bone-setting is a matter of address and attention to 
anatomical relations rather than to force." The patient recovered after 
a prolonged confinement, and at the last accounts was able to walk with 
crutches, the function of the right limb being fully restored, and the left 
h. 'in- shortened four and a half inches. 1 

It is unnecessary to say that the mode of production of this double 
dislocation was extraordinary, and that the facility with which the right 
hip was reduced at the end of six months was equally extraordinary; 
and that for these reasons the distinguished operator owed it both to 
himself and to the profession to supply a more complete history of the 
case, symptoms, and treatment than he has given. In so far as the cause 
and the mode of reduction are concerned, I have given my readers all 
that the report contains. 

The case reported by Bigelow, of reduction after three months, must 
he rejected also as a traumatic dislocation. Dr. Bigelow says himself 
that it was •• perhaps connected with hip disease," as there was evidence 
of disease in the joint for some time prior to the accident which was sup- 
posed to have caused the dislocation, and its subsequent existence was 
demonstrated by Binuses which formed and opened in the groin. He 
had also had for a long time disease of the bone near the ankle. 2 

Dr. Brown's case of reduction of ancient dislocation of the femur in 
a child eight year- old, cannot he considered in this connection, inasmuch 



1 Post, Med. Record, May 11, 1878, p. 366. 

low, Disloc. and Frac. of Hip, 1869, p. 111. 



ANCIENT DISLOCATIONS OF THE FEMUR. 877 

as lie states that the dislocation was probably caused by chronic rheu- 
matic arthritis. 1 

In the accompanying table I have inserted such cases as have up to 
the present moment the best claim to be regarded as actual reductions of 
traumatic hip-joint dislocations after a period of eight weeks. Some of 
them, however remarkable they may seem to be, there exists now no 
satisfactory means of verifying or of disproving. Others, even among 
those reported by my contemporaries, are so briefly and imperfectly re- 
ported that they do not seem to me thoroughly established — certainly 
not by that sort of testimony which science demands where unusual and 
extraordinary facts are recorded. 

While estimating the relative value of the several methods of reduc- 
tion. I have cited several examples of fracture of the neck of the femur 
in the attempt to reduce old dislocations. In some cases the results have 
been much more serious. 

A man. 29 years old, was received at La Pitie, Paris, on the 13th of 
May. 1868, with dislocation of the hip of seven months' standing. M. 
Broca attempted to reduce it, using a force of 480 lbs. No reduction 
was obtained, and the patient insisted upon leaving the hospital five 
days afterward. A fortnight then elapsed, when he presented himself 
at another hospital, with the hip enormously swollen, and died the next 
day of peritonitis. The autopsy showed that the head of the bone lay 
in the ischiatic notch, that it was held firmly by bundles of the torn 
capsule, and that the cotyloid cavity was much shrunk. Pus was found 
in the capsule, in the iliac fossa, in the articular cavities, and had found 
its way into the peritoneum, through the obturator foramen. 2 

The following case seems deserving of mention, for the reason that it 
is the first, so far as I am aware, in which an attempt has been made to 
reduce the dislocation after a subcutaneous division of the capsule : 

Thomas Jordan, aet. 28, of Utica, N. Y., was sent to me by my former 
pupil, Dr. Jenkins, in January, 1869, having a dislocation of his left 
femur upwards and backwards upon the dorsum ilii. His account of the 
case was. that seven months before lie was thrown in wrestling; a sur- 
geon was called on the following day, and finding a dislocation, he place* 1 
him under the influence of an anaesthetic, and, as he supposed, reduce* 1 
the dislocation by manipulation. 

The case did not come under the notice of Dr. Jenkins until :i few 
weeks before he was sent to me, and although the character of the acci- 
dent was recognized, no attempts were made at reduction. 

I found the limb rotated inwards, adducted, and shortened two inches. 
Before the class of medical students at Bellevue, assisted by Drs. Sayre, 
Crosby, Howard, and others, I made an attempt, January z9th 5 to break 
up the adhesions and reduce the dislocation, the patient being fully under 
the influence of ether. We were able to move the limb quite freely in 
various directions ; but after a trial of nearly an hour, we abandoned the 
attempt, having failed to accomplish reduction. 

cutaneous Dislocation en Dorsum Ilii; Reduction after several months, 
Fran* - A pamphlet. Boston Med. «nd Burg. Journ Sept. 29, 

1-70. 
2 New York Med Record, Dec. 16 



S7S 



DISLOCATIONS OF THE THIGH. 



Table of Traumatic Dislocations of the Hip, reduced after eight weeks. 



A f Time 

~ after Form of 

Operator. pa- Di8 , oca . dislocation . 

tient tion. 

vrs. 



Method of 
reduction. 



1 


s. Nott. 


33 


56 da\s 


On dorsum 

ilii. 


i Extension 


Despres. 


48 66 days 


Foramen 


Extension 






ovale. 


with ana?s 
thesia. 


3 


A. Crosby. 


... 68 days 




! Extension 












with arises 












thesia. 


4 


Pollock. 


72 


72 days 


Ischiatic 
notch. 


Extension 

with arises 

thesia. 


5 


Breschet. 




72 days 






6 


Dupuytren. 


23 


78 days 


Dorsum 
ilii. 


Extension 


7 


Kimball. 




3 mos. 






8 


Doutrelepont. 


7 


3 mos. 


Dorsum 
ilii. 


Extension. 


9 


Bayer. 




3 mos. 


Foramen 
ovale. 


Manipula- 
tion. 


10 


Blanc. 




3 mos. 






11 Dupuytren. 


25 


99 days. 


Dorsum 
ilii. 


Extension. 


12 W. L. Atlee. 




4 mos. 




Extension, 
with anes- 
thesia. 


18 Williams. 


8 


5 mos. 


Probably 


Anesthesia 










in ischiatic 












notch. 




M 


Bigelow. 


7 


5 mos. 


Dorsum 
ilii. 


Manipula- 
tion. 


16 


MEacQee. 




5 mos. 
and half. 




Manipula- 
tion. 


16 


lius. 




6 mos. 






17 


Dupierris. 


!■; 


6 mos. 


Dorsum 
ilii. 


Manipula- 
tion. 


18 


Blackman. 




6 mos. 






19 


Peltavy. 


34 


6 mos. 


Foramen 


Manipula-j 








ovale. 


tion. 


20 


Bigelow. 


27 8 mos. 


Dorsum 
ilii. 


Manipula- 
tion. 


2 J 


Carron du Vil- 
lare. 


8 mos. 


Foramen 

ovale. 


Extension.; 


22 


Smyth. 


'J7 9 mos. 


Dorsum 


Manipula- 










ilii. 


tion, with ! 
myesthesia. 




Baliceto. 




1 year. 







Sir Astley Cooper, Disloc. 

and Frac, etc., 2d Lond. 

ed., p. 50. 
Bull. Soc Chir., 1879, p. 

142. 

jTrans. Am. Med. Assoc, 
I vol. iii. p. 356, An. 1850. 

,iThe Lancet, 1880, vol. 2, 
p. 130. 

Brown, Boston Med. and 

Surg. Journ., Sept. 29, 

1870. 
Dupuytren on Diseases and 

Injuries of Bones. Lond. 

ed., 1847, p. 373. 
Northwestern Med. and 

Surg. Journ., June, 1870. 
Berliner Klin. Wochen- 
i schrift, 1876, No. 31, p. 

455. 
Prager. Med. Woch., 1880, 

No. 30. (Poinsot ) 
; Journ. des Conn. Med. 

Chir., 1870, No. 2. 
Dupuytren, op. cit., p. 375. 

Trans. Amer. Med. Assoc, 
vol. iii. p. 357, An. 1850. 

The Lancet, vol. i. p. 665, 
An. 1862. 

The Lancet, 1878, vol. i. 

p. 86. 
Amer. Journ. Med. Sci., 

Jan. 1871. 
G-allicinium Med.-pract., 

Ulm, 1700, p. 288. 



Western Lancet, April, 

1856, p. 253. 
Wiener Med Wochensch- 

rift, 1873, No. 47. 
Bigelow on Dis. and Frac. 

of Hip, 1869, p. 55. 
Malgaigne, op. cit., vol. 2, 

p. 868. 
New Orleans Journ. Med., 

Jan. 1, 1869, p. 71. 

Malgaigne, Frac. and Dis. 
Paris ed., 1855, vol. ii. 
p. 185. 



ANCIENT DISLOCATIONS OF THE FEMUR. 879 

A few days later I applied extension, by means of adhesive plaster 
and a cord, with a weight of twenty pounds. This was continued unre- 
mittingly until February the 24th, when he was again placed under the 
influence of ether before the class. Assisted by Drs. Stephen Smith, 
Howard, Cross, and others, attempts were made to reduce the bone by 
manipulation, but without success. Believing now that the untorn por- 
tion of the capsule, and particularly the ilio-femoral ligament, constituted 
the chief obstacle to the reduction, I introduced a long, firm, but narrow 
bistoury, which I had had made for the purpose, just above the tro- 
chanter major, carrying its point inwards until it touched the neck at the 
base of the trochanter. From this point, the edge of the knife being 
directed toward the head of the bone, I swept the point of the knife 
slowly along until the head was distinctly felt, the point touching the 
neck apparently in its whole length. This was accomplished without 
enlarging the external opening. While the incision was being made the 
limb was kept rotated outwards, and abducted as much as was possible, 
and it was felt to yield distinctly, so that both rotation outwards and 
abduction were more complete afterwards than before. I then divided 
also the tensor vaginae f em oris ; and now the attempts at reduction were 
repeated, both by manipulation and extension, but without success. 

The result of this attempt to reduce the dislocation by division of the 
ilio-femoral ligament, although unsuccessful, encourages a hope that it 
may sometimes succeed ; and I shall not hesitate to repeat the experi- 
ment, if a favorable opportunity is presented. 

In 1878, Dr. MacCormack, of London, 1 practised subcutaneous ten- 
otomy of the muscles for the purpose of reducing a dislocation into the 
foramen ovale, which had existed two years. The patient was nineteen 
years old. The section of the muscles gave no result ; and Dr. Mac- 
Cormack then exposed, by a free external incision, the articulation ; and 
finding the socket was nearly obliterated he resected the head of the 
femur, and obtained a satisfactory result. 

In 1876, Volkmann, 2 also, practised resection of the head of the femur, 
after having exposed the joint and divided the muscles extensively, in 
the hope that in this way he might effect the reduction ; but in which 
case, as in the case of MacCormack, the reduction was even then found 
impracticable. The patient was a man, set. 51, who had a dislocation 
into the perineum of about three months' standing, and which Volkmann 
had tried in vain to reduce by other methods. The head of the femur 
was found upon the dorsum of the ilium, to which point it had been car- 
ried by the previous manipulations. The head and neck were resected 
at a point below the trochanter, and the operation resulted in a complete 
recovery, and in giving to the patient a tolerably useful limb. 

M. Polaillon* reports the case of a man, aet. 16, who bad a dislocation 
upon the dorsum ilii. The dislocation had occurred more than six weeks 
before; and although repeated attempts were made to reduce the dis- 
location, commencing on the day following the accident, and by various 

1 MacCormack, St. Thomas's Bosp. Rep., vol. ix. p. 101. 

2 Volkmann. Banke, Berliner Klin. Wochenschrift, 1877, No. 25, p. 857. 

3 Polaillon, Bull. 8oc. de Chir. de Paris, 1883, Seance du 81 Jan. 



DISLOCATIONS OF THE THIGH. 

methods, it still remained unreduced ; but the head had been transferred 
from the dorsum to the foramen ovale, in which position it lay when M. 
Polaillon proceeded, with antiseptic precautions, to open the joint, and 
to Bever the Ligamentous and muscular attachments which prevented the 
return of the bone to its socket. Reduction having been effected, the 
wound was closed. The patient died on the fourth day. His death 
being caused, as it would appear, by septicemic infection. 

§ 7. Partial Dislocations of the Femur. 

Malgaigne declares that certain experiments made upon the cadaver 
led liim, at one time, to the conclusion that all primitive dislocations of 
the femur were incomplete, and that the old complete dislocations found 
in autopsies have become so consecutively. Later observations have 
taught him to correct this error, yet he still finds "incomplete backward 
dislocations quite common, and incomplete dislocations in all the other 
directions much more common." 

I have more than once found occasion to call in question the accuracy 
of Malgaigne's views in relation to partial dislocations, the relative fre- 
quency of which, as traumatic accidents, he seems constantly disposed 
to exaggerate greatly. I cannot see the propriety of calling those cases 
partial dislocations, in which the head of the bone has fairly left the 
cotyloid cavity, and mounted upon its margin, even if it remains in this 
position without tearing the capsule ; since the articular surfaces are 
uow as completely separated as if the capsule had given way, and the 
head of the bone had escaped through the laceration. It is in fact a 
complete dislocation. But I doubt very much whether the head of the 
bone ever rests upon the margin of the acetabulum without tearing the 
capsule, unless it has previously undergone certain pathological changes, 
such as I have already described; at least I cannot hesitate to reject all 
those examples in which the head of the femur is supposed to rest upon 
the upper or outer margin of the acetabulum ; and if I permit myself to 
speak of incomplete dislocations at all in this connection, I shall reserve 
the term for those rare cases in which the head of the femur becomes 
engaged in the cotyloid notch, after breaking down the fibrous band 
which, in the natural state, is continuous with the rim of the acetabulum. 

( )f this fonn of dislocation, I think I have met with two examples ; one 
of which was in the person of the boy Lower, already mentioned, whose 
thigh was reduced accidentally by his father; and the other occurred in 
;i boy fifteen years of age, residing at that time in Rutland, Vermont. 
He was brought to me on the 28th of May, 1842, by Dr. Haynes, of 
Rutland, at which time the dislocation had existed five years. His ac- 
count of himself was that in walking upon a slippery floor, his left leg 
slid outwards and backwards in such a manner that when he fell it was 
fairly doubled under his back. On the tenth day following the acci- 
dent he began to walk with some help, and he has continued to walk 
ever since, but with a manifest halt. Three months after the injury was 
received, it was first seen by several surgeons, who pronounced it a dis- 
location, and attempted reduction without mechanical aid, but were 
unsuccessful. 



COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 881 

When the young man was brought to me, the limb was neither length- 
ened nor shortened, but the thigh was forcibly abducted and rotated out- 
wards. It could not be flexed nor greatly extended. The head of the 
femur could be distinctly felt, as it lay anterior to the socket, but not 
sufficiently far forwards to rest upon the foramen thyroideum. 

J. C. Warren, of Boston, has reported a similar example in a child six 
years old, who was brought. April 21, 1841, to the Massachusetts Gene- 
ral Hospital. Dr. Hale, who saw the lad at the end of two weeks, 
thought it a dislocation, but it had been treated by another surgeon as 
a case of hip-disease. The dislocation had now existed eight or ten 
weeks. The limb was a little lengthened, abducted, turned outwards, 
and advanced in front of the body, with very slight motion of either flex- 
ion or extension, and almost no tenderness about the joint. Dr. Warren, 
also, was able to feel indistinctly the head of the bone " immediately 
external to, and in contact with, the insertion of the triceps and gracilis 
muscles." 

An attempt was made by manual extension and manipulation to ac- 
complish the reduction, but without success. 1 

It is probable that both the above cases, which I have described at 
length, were examples of partial dislocations ; yet I cannot conceal from 
others a doubt which I actually entertain whether they were not, after 
all. only examples of hip-joint disease, arrested after having wrought 
certain slight pathological changes in the joint and the tissues adjacent. 
If. however, they were not examples of incomplete dislocations of the 
hip-joint, then I question whether any such cases have ever occurred as 
simple traumatic accidents. 

I 8. Coxo-Femoral Dislocations, complicated with Fracture of the Femur. 

Such complications are exceedingly rare, but it will not do to deny 
their possibility ; although in some of the cases reported, the testimony 
is bo incomplete as to leave a doubt whether the surgeons have not erred 
in their diagnosis. 

James Douglas has reported a case of dislocation upon the pubes, com- 
plicated with a fracture of the neck of the femur, the actual condition of 
which was verified by an autopsy ; the patient having died twelve years 
after the injury was received. The head of the femur still remained 
above the pubes. and was in no way connected with its neck or shaft. 
The upper end of the femur projected in the groin, lying upon the inside 
of the femoral artery and vein. Many other curious pathological changes 
had also occurred. 2 

The well-authenticated examples of reduction of the dislocation, where 
the femur was broken also, are -till more rare: and several of the re- 
corded example- which my researches have discovered, need additional 
confirmation. 

John Bloxham, of Newport, in the Isle of Wight, claims to have re- 
duced a dislocation of the femur on the pubes, which was accompanied 

\V '. - irg. Journ.. vol. xxiv. p. 220. 

- Amer. Journ. rol. xxxiii. p. 4o">, from Lond. and Bdin. Month, 

Journ ■' - D 



882 



DISLOCATIONS OF THE THIGH. 



with a fracture of the thigh a little above its middle. The following is 
the account of this interesting case, which I find in the London Medico- 
< 1 hirurgical Review, copied from the Medical Gazette of August 24, 
1833. 1 regret that I am unable to see the account as published in 
the Gazette, which might supply some circumstances important to a full 
appreciation of the case: 

On the seventh or eighth day after the accident, "the patient was 
laid on his back upon the bed, and kept in that position by means of a 
sheet passed across the pelvis and fastened to the bedstead; another 
sheet was also passed over the left groin, and secured in a similar 
manner. The dislocated and fractured limb was then inclosed in splints, 
one of which extended up the back of the thigh as far as the tuberosity 
of the ischium. Pulleys, which were secured to a staple in the ceiling, 
placed at the distance of a foot to the right of a point vertical to the 
patient's navel, were then attached to a bandage fastened around the 
splints as high up as possible. 

" The foot was raised with the knee extended, so as to bring the limb 
nearly to a right angle with the line of the tackle, when by drawing 
gradually on the cord, in the course of about ten or fifteen minutes the 
head of the bone was rendered movable, and was brought considerably 
more forwards. I then began to press on the head of the bone, so as to 
push it downwards, while the pulleys held it partially disengaged from 
the pelvis. In a few minutes the head of the bone passed over the 
ridge of the os pubis, and I then directed the foot to be raised a little 
higher, which by putting the glutei muscles more upon the stretch was 
calculated to render them more efficient in drawing the bone into its 
proper place. By this manoeuvre, the head of the bone was drawn 
backwards, and on the foot being more elevated and the cord slackened, 
it continued to recede from my fingers till the trochanter major made its 
appearance in the natural situation, and the reduction was found to be 
perfectly complete. 

"Lest the head of the bone should slip backwards on the dorsum ilii, 
I directed an assistant to apply firm pressure during the latter part of 
the process, above and behind the acetabulum. 

" The apparatus was then removed, the thigh bound up in short splints, 
and the patient laid upon a double-inclined plane. No symptoms of 
inflammation appeared afterwards about the joint. Passive motion was 
employed at the end of a week, and occasionally repeated during the 
whole reparatory process." 1 

Without intending to question the accuracy of the statements in this 
case, which, in the main, seem to bear the marks of credibility, I 
most express my surprise that so little difficulty was experienced in the 
reduction if the femur was actually broken, no more, indeed, than is 
usually experienced when the bone is not broken; and that Mr. Blox- 
hain was able to employ safely passive motion at the end of a week. 

Charles Thornhill relates, in the London Medical Gazette for July, 
1 836, a case of fracture of the femur through its upper third, in a man aet. 
40, with dislocation into the ischiatic notch ; which dislocation, he assures 



1 Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1833. 



COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 883 

us. was reduced at the end of six weeks. But it is much more probable 
that, instead of reducing a dislocation, he refractured the bone. During 
more than one hour and a half, aided by pulleys, tractions and manipu- 
lations were made in almost every direction. 

The upper part of the thigh was lifted with all the strength of one 
man by means of a jack-towel: it was violently rotated, adducted, and 
abducted. Both the perineal and the knee band gave way, from the 
excess of the force employed : and, finally, the head of the femur re- 
sumed its place with an audible crash. After which the " limb was 
of nearly equal length with the other;" but there remained an "im- 
mense deposit" around the acetabulum. 1 

Malgaigne says that M. Eteve found a poor fellow with a dislocation 
of his left thigh backwards, a fracture near its middle, a penetrating 
wound of the knee, and a fracture of the fibula in the same leg. With- 
out delay he proceeded to reduce the dislocation by directing two 
assistants to support the body, three to support the leg, and two more 
to make extension from a towel tied not very tightly around the thigh 
above the fracture. # The leg was then extended upon the thigh, and 
the thigh flexed upon the pelvis until it was at a right angle with the 
body ; and after a gradual extension had been made in this direction, 
M. Eteve pushed with all his strength the head of the bone into its 
socket. Of which case Malgaigne justly remarks that the " extension " 
practised by the surgeon was only imaginary. 2 If the reduction was 
accomplished at all. it was by manipulation and pressure. 

Finally, Markoe relates, in the paper to which I have already 
several times made allusion, the case of a boy set. 8, who was admitted 
into the New York City Hospital, on the 29th of June, 1853, with a 
compound fracture of the right thigh, a simple fracture of the left, and 
a dislocation of the head of the right femur upwards and backwards upon 
the dorsum ilii. 

When placed upon the bed, the right limb lay obliquely across the 
abdomen of the boy, with the foot resting against the axilla of the left 
side. " The house-surgeon, to whose care the case fell on admission, 
took the injured limb in his hands very carefully, carried it over the 
abdomen to the right side, and then abducted it and brought it down 
toward the straight position," during which procedure the bead of the 
bone is supposed to have resumed its place in the socket. 3 

Mich is the account furnished of the symptoms and treatment of this 
extraordinary case: too meagre, certainly, to entitle it to much confi- 
dence, or to permit us to draw from it any practical inferences. We are 
not even informed what was the name of the young man who alone <;nv 
and treated the case, nor what was his responsibility ;i- ;i surgeon. 

I have been unable to find any other examples of fracture of the 
femur complicated with dislocation : and, rejecting ;n least Mr. Thorn- 
hill's case a- altogether incredible, the proper conclusion would be. thai 
reduction is sometime- possible in recent cases, if the surgeon will resori 

1 Amer. Journ. Rfed. 8ci., vol. xxy. p 21fl 

2 Malgaigne, op. cit., torn. ii. }> 206; from Gazette M«'<1.. L888, p. 7">7. 

3 New York Journ. Med., Jan. 1866, p. 80 



884 DISLOCATIONS OF THE THIGH. 

promptly, before swelling and muscular contractions have taken place, to 
manipulation combined with pressure upon the head of the bone. Indeed, 
it is probable that pressure alone is the means upon which the success 
will finally depend. Richet says that he has several times dislocated the 
femur in the cadaver ; and then having sawn off the head so as to repre- 
sent a fracture, he has always been able to push the head of the bone 
easily into its socket. 1 By seizing the moment then when the patient is 
Laboring under the shock, or by placing him completely under the influ- 
ence of an anaesthetic, no resistance will be offered by the muscles any 
move than in the cadaver, and the reduction may, perhaps, be easily 
effected. 

1 have no confidence that anything can be accomplished by extension ; 
nor do I think it will be best to wait until the femur has united, since 
such delay will probably render the reduction impossible. 

§ 9. Voluntary or Spontaneous Dislocations of the Femur. 

Examples in which persons, having suffered no disease of the hip- 
joint, have been able voluntarily to dislocate the femur, have, from time 
to time, been recorded, but I am not aware that any dissections have 
ever been made in these cases. I shall, therefore, not attempt any expla- 
nation of the facts, but simply record them as matters of curious interest, 
and for the purpose of inducing others to make of them a subject of 
investigation. 

Malgaigne remarks that " certain persons, without having suffered from 
any injury or disease of the joint, have the singular faculty of dislocating 
and reducing the femur voluntarily. Portal saw an example in the per- 
son of the Abbe of Saint-Benoit. Humbert mentions a surgeon near 
Troves, who dislocated the femur up and down, and reduced it by the 
simple act of the muscles, without the aid of his hands. He reports at 
the same time, the curious history of a person endowed with the same 
power, who after a quarrel produced the dislocation, and then claimed 
damages, attributing the accident to the violence of his adversary." 
The same author speaks of cases reported by Coulson, Solly, and Stan- 
lev, and the one hereafter to be mentioned alluded to by Sir Astley 
I looper, making in all seven cases. It does not appear, Malgaigne adds, 
thai " this laxity impairs the functions of the limb ; it is nevertheless a 
subject which demands to be better studied." 2 

Sir Astley ( Jooper says, " I have received from Mr. Brindley, surgeon, 
of Wink Hill, an account of a dislocation of the os femoris, which the 
patient is able to produce and reduce when he chooses. The man is 
fifty years of age." 3 Sir Astley has not given any further account of 
this case. 

Samuel Cooper Bpeaks of this matter briefly as follows: "There are 
instances recorded of persons who could dislocate their thigh-bone spon- 
taneously, and afterwards replace it again without assistance. A gen- 

k Journ. Med., .March, 1854, p. 293; from Bullet, de Ther. 

2 Humbert, Essai but lea lux. spontanees du femur, 1835, p. 35. From Malgaigne, 

\.,l ii. j,. 888, He also refers to Gaz. des Hopitaux, 1841, p. 104. 
s Brindley, Sir Astley Cooper on Disloc. and Frac. Preface to 2d Lond. ed., 1823. 






VOLUNTARY DISLOCATIONS OF THE FEMUR. 885 

tleman, who attended my lectures, informed me of a person so circum- 
stanced, and related some of the particulars to me. I suppose that, in 
such cases, there must be an unusual relaxation of the synovial mem- 
brane, a rupture of the ligamentum teres, and perhaps an imperfect state 
of the acetabulum.'' 1 

Dr. William Gibson mentions the two preceding cases, and adds, a A 
third was related in an inaugural essay, by Dr. Lewis, of North Caro- 
lina, who graduated at our University (University of Pennsylvania), in 
the spring of 1841.'" 

Dr. Bigelow has seen two cases, and reports a third from Prof. E. M. 
Moore, of Rochester. In the first of these the hip was at first dislocated 
by an accident ; and in a few hours it was reduced by manipulation. 
Eight days after the accident, in attempting to walk, it was again 
partially dislocated, when the patient himself replaced it by pushing 
against it with the hand, and pressing with the other against the knee. 
Since then the man has been able to dislocate the bone backwards upon 
the edge of the socket by muscular action, and to reduce it by throwing 
the leg out sideways. In the second case seen by Bigelow, " the 
phenomena are much like those just described." 

Dr. Bigelow regards them both as subluxations, and speaking of the 
first case, he says the limb " exhibits slight flexion, shortening, and 
inversion." The case seen by Prof. Moore, and of which Prof. Moore 
obtained photographs (Figs. 361, 362), is described as follows : John B. 
Parker, private soldier, U. S. V., was skirmishing up a hill, May 13, 
1861, and sprang suddenly back to avoid the gun of a comrade in ad- 
vance. His left foot became entangled, and his weight dislocated the 
hip. He felt the injury, and supposed it out of joint. Some comrades 
put it in, and he immediately resumed his skirmishing, and marched 
seven miles, from 10 a. m. to 6 p. M. He rested at night, and went on 
duty the next day, sharpshooting and crawling all day. He continued 
this kind of duty nine days, and subsequently was on duty in other ways, 
and did not enter a hospital uutil the fifteenth day after the accident. 
When the case was reported to Dr. Bigelow, the man could dislocate the 
hip at any time by pressing the foot on the floor, to fix it firmly, con- 
tracting the adductors, and throwing out the pelvis, when the head 
"suddenly leaves the acetabulum, and goes on the dorsum." There is a 
Blight inversion while the limb remains in this position. Dr. Bigelow 
thinks that this is also a subluxation. 3 

The following case was reported to me in 1865, by John M. Forrest, 
M.D.. of Portland, Maine to whom the man presented himself a- a 
" substitute," while Dr. Forrest was in the service of the U. S. Army. 
The application was rejected: 

•• William G. Gliddon, aet. 37. farmer, says thai he has been able t<> 
dislocate and replace the- femur at the left hip-joint since lie was a boy. 
It is u"t tie- result of any injury or disease, 30 far :i- he knows. Il<- is 
in good health, and hi- muscular development i- complete. He accom- 

1 Samuel Cooper, Pint L York ed . 1844, vo\ ii. p 

- Surgery, 6tn ed., An. 1841, vol. i. p 887 

:; Moore, Bigelow. I> Fractures of the Bip, by Henry J. Bigelow, 1809, 

p. 112. 



886 



DISLOCATIONS OF THE THIGH. 



plishea the dislocation by throwing the weight of his body upon the left 
leg, and then contracting certain muscles about the hip. The reduction 
i- generally more difficult than the dislocation, sometimes requiring the 
aid of his hand. When the head of the bone is out, there is a marked 
projection above and behind the trochanter major, apparently caused by 
the pressure of the head in this situation; the limb is very slightly if 
at all everted ; Avhilc out of place it causes pain ;. and after a few repe- 



FlG. 361. 



Fig. 862. 





Voluntary subluxation upon the dorsum ilii. Case of Parker. (From Bigelow and Moore.) 

titions the pain becomes so great as to compel him to desist. The limb 
was doI measured while it was dislocated. When the limb is in position 
he docs not walk lame." 

Dr. Maurice Perrin 1 brought before the Surgical Society of Paris, in 
i 859, a man aged 22 years, who when 10 years old had' suffered a disloca- 
tion of the right hip in consequence of a fall from a horse, in which his leg 
was caughl in the harness, and his body suspended in a position of forced 
adduction. ( ha the following day it was reduced. Two or three months 
later it was reproduced by a slight misstep. At a later period he was 
found to be able to dislocate and reduce the dislocation at will. When 
presented to the Surgical Society this fact was verified, and admitted by 
Chassaignac, Marjolin, .Morel Lavallee, and many others who were 
present. 

The following case came under my personal observation: Dr. William 
<;. 8., Set. 24, received an injury on the outside of the right knee, in 

1 Perrin, Gaz. dea Hop.. 1859, p. 307. 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 887 

February, 1862. from the kick of a horse. There was no apparent injury 
of the hip. On the fourteenth day after the accident he rode forty miles 
on horseback, which was followed by some stiffness in the right hip. 
Two weeks later, in mounting his horse, he felt something slip in the 
hip-joint. From that day until this, a period of four years, he has 
been able to reproduce the same slipping voluntarily, and which phe- 
nomenon I recognize as a dislocation upwards and backwards. I have 
examined him more than once, and he has dislocated and reduced the 
dislocation in my presence repeatedly. Planting his right foot firmly 
upon the floor a little in advance of the left, with his toes turned out, he 
throws his weight upon the right leg by carrying his pelvis well over to 
the right, and then contracts powerfully the gluteal muscles. Instantly 
the head leaves the socket, and seems to mount upon the dorsum ; the 
trochanter major becomes rotated inwards, causing a slight inward rota- 
tion of the leg and foot. He can do the same when lying on his back, 
but not with the same ease. Reduction is accomplished without change 
of position, but by what precise manoeuvre I have not determined. The 
reduction is more quiet, and less sudden, apparently, than the dislocation. 
Both manoeuvres are accompanied with some pain. He is not lame, nor 
does the dislocation take place without his volition. I have seen one 
case, also, which, although pathological in character, was nevertheless 
caused by an early injury, and as such may properly be noticed in this 
connection. 

Dr. 0. Gillett. set. 65 (1867), of Westernville, Oneida Co., N.Y., was 
injured in his left hip-joint when 16 years old, by lifting a heavy 
weight. He felt at the moment something give way in the joint, and 
he has been lame ever since; at first he was quite lame, but after a 
time the soreness about the joint diminished, and up to within about 
three years the lameness was chiefly due to a lack of development in 
the limb. Since then the joint has again become tender, and during 
the last nine months he has been able to throw the head of the bone 
out of the socket, backwards and upwards. Indeed, the bone is dislo- 
cated whenever he sits down, and resumes its place again when he 
stands up. It is quite apparent that the upper and outer margin of 
the acetabulum is partly absorbed; and probably, also, the head and 
neck of the femur are in some measure deformed and absorbed. The 
dislocation is apparently incomplete; and while it exists the thigh is 
abducted and slightly rotated outwards. This abduction ami outward 
rotation do not properly belong to a dislocation upon the dorsum of 
the ilium: but as the condition of the joint and of the adjacent muscles 
i- abnormal, they will not require t«. bo explained. 

Deininger 1 relates the case of a retired soldier, who stated to him that 
when 7 pears old lie met with an accident which caused, m- was believed, 
a dislocation ofhia thigh backwards. The dislocation was not reduced; 
an abscess formed: and at the end of fourteen week- ;i spontaneous re- 
daction ensued After a time tie- patient began to observe ••" slipping of 
the joint, and when examined by Deininger the head of the femur was 
; h step dislocated backwards, with the characteristic noise, but 

"- Deininger, Deutsche Milil itschrift, iii 5 1874. 



888 P1SL0CATI0NS OF THE THIGH. 

again immediately restored to its normal position by muscular contrac- 
tion alone. 

Karpinski 1 reports the case of a man who had dislocated his left hip 
when 16 years old. Five years later, when seen by Karpinski, he was 
able to dislocate the femur upon the dorsum ilii by resting the weight of 
his body upon the left foot, and then turning his body to the left. Re- 
duction was effected by muscular contraction alone. 

In some respects the most remarkable example which has come to my 
knowledge, is that of Charles H. Warren, the celebrated contortionist 
and acrobat. Having myself made a careful personal examination of the 
man, and having observed that he does actually subluxate other limbs 
than the thigh, it has seemed to me that it would throw light upon this 
somewhat obscure class of cases if I were to give his history briefly, and 
describe in detail all the phenomena observed by me. My examination 
of him was made in 1879, when he was thirty-one years old. 

Mr. Warren was born in Schuylersville, Saratoga Co., New York, in 
1848. His parents were healthy, and neither of the parents nor either 
of their five children, except Charles, possessed his peculiar muscular 
development or power of dislocating the bones. His maternal grand- 
father is said to have possessed a similar power, but in a much more 
limited degree. In his own case it was first noticed in his infancy, soon 
after he began to run about, that he w T ould suddenly fall while running 
across the floor; and it was soon ascertained that he had been tripped 
up by the sudden displacement of his hip-joint, but the fall would re- 
store it to place and he would get up and again run about. This is 
his own account of his case at this early period of life, and it may or 
may not be correct, as I am not informed that any medical man was ever 
consulted. His statement, however, finds a confirmation in the fact that 
an infant son of Mr. Warren, now dead, had the same peculiarity. He 
has also a little daughter, now living, in whom the same phenomenon, so 
Ear as the accidental dislocation of the hip-joint is concerned, is mani- 
fested. He has had no other children, and his wife is a healthy and 
well-formed woman. In his own case this tendency to accidental and 
involuntary dislocation of the hip-joint only lasted two or three years 
after he began to run about. Since then, it only occurs by an act of voli- 
tion, and under the powerful contraction of the muscles. It is not even 
apt to accur during his performance of gymnastic and contortion feats. 

As a hoy. Warren ran about as other children and at five years went 
to school, hut when eight years of age he left home and joined a travel- 
ling circus. At eighteen he began to work at the trade of car-making, 
hut soon returned to the circus. 

I have called attention to these historical details, because they seem 
to illustrate — -first, that Warren had a congenital "relaxation of the liga- 
mente and capsules of the joints; and second, that his prodigious mus- 
cul.ir development was the result of early and long-continued muscular 
exercise; while the daily practice of contortion maintained the ligaments 
and capsules in their original abnormal condition. There is, therefore, 
in this case ;i combination of anatomical conditions rarely met with, 
namely: a relaxation of one class of structures or tissues, and an unusual 

1 Karpinski, Idem, ii. 3, 1873, p. 157. (Poinsot.) 



VOLUNTARY DISLOCATIONS OF THE FEMUR 889 

power of action and contraction in another. We often see persons who 
have congenital or acquired (pathological) relaxation of the articular 
ligaments, but this is associated in most cases with muscular weakness. 
So also there are frequent examples of great muscular power, the result 
of exercise, but the joints are compact also. None of them have the 
power of dislocating their bones by muscular action. Mr. Warren in- 
forms me that Walter Wentworth, a professional contortionist, now about 
forty-five years of age, and weighing perhaps 115 pounds, is probably more 
flexible than himself, but possesses rather less muscular power, yet he is 
very strong. John Santiago de Gibinois and George Mankin are pro- 
bably as strong as himself; Lister, of the New York circus, now dead, 
was probably superior to any one who has ever lived as a contortionist. 
The latter died only two or three years ago, at the age of forty-eight, 
and practised successfully his profession to the last days of his life. 
Yet not one of these men had the power of dislocating his bones which 
Warren possesses. It is clear, therefore, that we must ascribe Warren's 
peculiar power in this respect to a congenital abnormity, namely, a great 
capacity and lengthening of the capsular structures, united with later 
muscular development from exercise. 

Warren is rather above the average height, slender, and well propor- 
tioned. 

Inferior Maxilla ; Partial Dislocation Forwards. — This is accom- 
plished probably by the action of the external pterygoid muscles. There 
is nothing worthy of special note in this, inasmuch as the ability to dis- 
place the condyle to this extent is not very unusual. The condyle re- 
sumes its place the moment the action of the muscles ceases. 

Clavicle ; No Displacement. — He has no power to displace the clavicle 
at either articulation. 

Scapula; Displacement of Lower Angle. — This displacement is very 
remarkable, the lower angle of the scapula being lifted upwards and 
outwards until it lies nearly on a level with the top of the shoulder, and 
is made to project far backwards. We are enabled here to study care- 
fully the mechanism of this displacement, an example of which is every 
now and then reported in the journals as a "dislocation" of the scapula. 
It has been ascribed variously to a partial paralysis of the latissimus 
dorsi, in consequence of which the somewhat feeble hold which it has 
upon the inferior angle of the scapula is relaxed, and it is unable to 
retain the angle in its place ; — to a detachment of this muscle from the 
angle in consequence of some violence; — to paralysis of the serratus 
major anticus ; — and by one writer, to paralysis of the rhomboid mus- 
cles. 

In the case of Warren, it is apparent that it is accomplished solely by 
the action of the rhomboideus major, which muscle he has the ability to 
call into vigorous activity, while he suspends the action of the rhom- 
boideus minor, the serratus magnus, the latissimus dorsi and other mus- 
cles. We can even trace the fibres of the rhomboideus major as it lies 
in a sTiite of contraction underneath the trapezius. When tin- muscle 
ceases to contract, the angle fall- to it- place spontaneously. 

It is probable that a- we see it presented occasionally in other persons, 
it is. due most often to a paralysis of tie- serratus major anticus ; possibly 



890 DISLOCATIONS OF THE THIGH. 

Bometimea to a loss of power in the latissimus, and even occasionally to a 
disruption of the attachment of the latissimus; but it is impossible that 
i: should be duo to a paralysis of either of the rhomboids, as has been 
suggested. Of course I exclude from consideration, now, all those ex- 
amples of scapular projections which are due to spinal distortions, and 
which are purely mechanical, and have therefore nothing in common 
with this case. 

//< ad of the Humerus; Subglenoid Subluxation. — By the action, 
apparently, of the latissimus dorsi, aided, perhaps, by the lower fibres 
of the pectoralis major, Warren displaces the head of the humerus down- 
wards, until it rests upon the lower margin of the glenoid cavity, causing 
a very marked depression under the acromion process, and increasing 
the length of the arm, as measured from this process, about one inch. 
He soon becomes weary of holding it in this position, and then when he 
relaxes the muscles, the head rises to its socket without noise or sensation. 
His ability to perform this feat, is equal in the two arms. 

Elbow-joint. — The elbow-joint admits of a slight increase of lateral 
motion, above what is usual, and the backward movement, or extension, 
is greater than is usual with adults ; but he has no power to cause either 
a dislocation or subluxation at this joint. 

Wrist-joint ; Backward, Forward, and Lateral Subluxation. — By 
the action of the muscles alone he displaces the carpal bones backwards 
or forwards, causing in each case a partial dislocation. He cannot, how- 
ever, cause a lateral dislocation without first grasping the wrist with the 
opposite hand — the wrist being grasped firmly by its radial and ulnar 
margins — when, by the action of the muscles, the carpus is thrown fully 
half an inch to either side. When the carpus is thrown to the radial 
side, the hand falls to the ulnar side; and the reverse happens when the 
carpus Is thrown to the ulnar side. When the muscles are relaxed, the 
carpus resumes its position spontaneously, and without sound or sensa- 
tion. 

Phalangeal Articulations; Subluxations. — He is able to subluxate 
all the articulations of his fingers, including the thumb. The subluxa- 
tions backwards and forwards are effected by muscular action, but the 
lateral dislocation only by the help of the other hand. 

Htp : a Vpparently Complete Dislocation upon the Dorsum Ilii. — It is 
in the hip that the greatest scientific and surgical interest of this case 
centres. After a careful study of the phenomena accompanying certain 
motions of the hip-joint in the person of Warren, I have felt compelled 
to accept of the theory that he causes a true and complete dislocation 
upon the dorsum of the ilium. 

W c notice that while the patient is standing nude, his form is perfect, 
except that both feet turn out a little more than is usual with others. 
With a moderate effort of the muscles the head of the bone seems to 
move m its socket, and to be carried upwards and backwards upon the 
dorsum ilii. The change of position occurs suddenly, and is accompanied 
with a sensation to the hand as of a bone slipping suddenly into its socket 
— a sort of heavy thud. When he has dislocated his right leg, he stands 
upon his left leg, the right being lifted from the floor, the thigh a little 
fhxed upon the body, the leg flexed upon the thigh, with the toes turned 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 891 

a little in. He says, that knowing that it ought to turn in a little more 
to represent the appearance which the limb usually presents in this dis- 
location, he sometimes, when exhibiting himself, turns it in more ; but 
this is the position, only slightly turned in, which it naturally takes. 
Looking for the trochanter major, we find that it has been carried up- 
wards and backwards full two inches. The head of the bone we are 
unable to find. It is very difficult to make a comparative measurement 
of the two limbs when one is thus displaced, but. so far as I can deter- 
mine, the right limb is shortened at least one inch, probably more. 

Warren repeated the dislocation several times : the bone always return- 
ing quietly to its place after each displacement, without any sound or 
sensation like that which accompanied its displacement. The same 
experiment was made with the opposite thigh, and with the same results. 
Finally, he was laid upon the floor, upon a blanket, and he produced the 
dislocations equally, but apparently with little more muscular effort. 

There seem to be but two possible explanations of the phenomena 
presented in the case of the femur : either they are produced by the 
trochanter rotating outwards, and pressing firmly against the anterior 
margin of the glutieus maximus. until suddenly it becomes disengaged 
and slips under this muscle, while the head of the bone remains in its 
socket : or. there is a veritable dislocation of the head of the bone. 

In favor of the first supposition it may be stated again, that when the 
displacement in the case of Mr. Warren has occurred, the trochanter 
major is removed backwards and upwards full two inches ; it remains as 
prominent as it was before, and the head cannot be found ; while in the 
usual dislocation upon the dorsum the trochanter turns forwards, and is 
less prominent than it was before : and the head of the bone may usually 
be felt when there is no swelling. How then could this be a dislocation? 
Plainly only by supposing that there was such an abnormity of the joint 
— an almost total absence of the rim of the acetabulum in that direction — 
and perhaps such a broadening of the head, and shortening of the neck, 
us would permit the head, neck, and trochanter to be drawn up and back 
by the gluteal muscles, without changing the relations of the line of their 
common axis to the outer face of the pelvis; that is. without any inward 
tilting of the trochanter. This would assume the existence of anatomical 
conditions that are not proven, but only deemed possible. 

If the limb is actually shortened, however, there must lie a dislocation, 
and I think it is; but inasmuch a- the accuracy of any measurements 
under these circumstances might be fairly questioned, we shall for the 
moment dismiss this argument also. 

There now remains only this important fact, that while the trochanter 
major i- carried back, the too are no longer very much turned outwards, 
as they were before the displacement was made; nor do they point for- 
wards, but actually a little inwards. So that in fact there is about as 
much inward rotation of the foot as we could have required \<> iiMli<;it<- 
;in outward dislocation. But it is plainly impossible that the head of* the 
femur should remain in it- pocket, while the trochanter is rotated out- 
wards two inches, and tin- kin.-. foot, and toes not accompany this out- 
ward rotation. Certainly it is impossible that tin- whole lower portion 

of the limb should rotate inward-, as it actually floes, while the trochanter 



892 DISLOCATIONS OF THE THIGH. 

is strongly rotated outwards. These considerations, it seems to me, must 
exclude the supposition that there is here only a rotation of the trochanter 
outwards, and a consequent muscular displacement. 

Whatever difficulties there may be in the way of supposing that this 
is a dislocation, fchey are not insuperable if Ave assume the existence of 
Borne abnormity in the construction of the joint and of the neck. It 
is possible even, that what we believe to be the trochanter moved back 
is actually the head of the bone, and that it is the trochanter which is 
lost : tor the change of position occurs so suddenly that neither by the 
sight, nor with the hands placed upon the trochanter, can we follow the 
change of position. I only discover, after a sudden commotion, that 
there is no longer a projection where the trochanter was felt, and which 
I marked with a pencil in order not to be deceived ; and that there is a 
projection which resembles it precisely, so far as we can determine, tw r o 
inches farther back and upwards. Possibly, I say, this new projection 
is really the head, somewhat changed from its normal form ; but I do not 
think so. Perhaps nothing but an autopsy can determine this and other 
points connected with the case. 

Knee-joint ; Rotation and Subluxation. — Mr. Warren has no power 
t<> displace the knee-joint by muscular action ; but seizing the leg while 
it is flexed, he can rotate the tibia laterally very freely, and cause the 
head of the tibia to project beyond the line of the articulation half an 
inch or more. 

Patella. — He has no power to displace this bone. 

Ankle-joint. — With his hands he can abduct and adduct this joint 
almost to a right angle with the leg. 

Tarsal Joints. — By the aid of his hands he can imitate the extremes 
of varus and valgus. 

Phalanges of the Toes. — They are loose, but not so loose in their 
articulations as the phalanges of the fingers. 

Adams, 1 of Glasgow, describes the case of a young man who, when 20 
years of age, in trying to imitate an acrobat dislocated his thigh, which 
he reduced without assistance. After this he found himself able to dis- 
locate either hip at pleasure. In order to accomplish this he raised the 
foot of the limb which he wished to dislocate, until only the toes touched 
the floor, and then suddenly flexed and adducted the limb. On ceasing 
the muscular contraction the bone returned spontaneously to its socket. 
This patient, who was examined three years after the original accident, 
was able also to displace voluntarily the inferior maxilla. 

Chassaignac 2 furnishes an account of a vaulting mountebank, who had 
;i congenital dislocation of both hips upon the iliac fossse, which he was 
able voluntarily to convert into ischiatic dislocations. 

1 Adams, Glasgow Med. Journ., Oct. 1882, vol. 8, No. 4. 

2 Chassaignac, Bull. Soc. de Chir. de Paris, Seance du 28 Janv. 1853, p. 391. 



DISLOCATIONS OF THE PATELLA OUTWARDS. 



893 



CHAPTER XVIII. 



DISLOCATIONS OF THE PATELLA. 



§ 1. Dislocations of the Patella Outwards. 

Causes. — In the majority of cases this dislocation has been occasioned 
by muscular action ; and especially is this liable to occur in persons who 
are knock-kneed, or whose external condyles have not the usual promi- 
nence anteriorly. It may be caused by suddenly twisting the thigh 
inwards while the weight of the body rests upon the foot, and the leg is 
thus kept turned outwards ; or by falling with the knee turned inwards 
and the foot outwards. Occasionally it is the result of a blow received 
upon the inside, or upon the front and inner margin of the patella. In 
some persons there seems to exist a preternatural laxity of the liga- 
mentum patellae or of the tendon of the quadriceps extensor, which 
exposes the subject to this accident from very trifling 
causes. Fergusson says he has known it to be occa- Fig. 363. 

sioned by a child's stepping upon the knee of a person 
lying in bed ; and Skey says he has seen two cases 
which occurred spontaneously during sleep. B. Cooper 
has seen a young lady who frequently dislocated her 
patella outwards by merely striking her toe against 
the carpet, or in dancing. Boyer, Sir Astley Cooper, 
and others mention similar examples. 

Pathological Anatomy. — Most frequently the dislo- 
cation is only partial, the inner half of the patella 
resting upon the articular surface of the outer con- 
dyle ; and in consequence of the peculiar obliquity of 
these surfaces, together with the action of the vasti 
and rectus fern oris, the outer margin of the patella 
becomes tilted forwards. 

If the dislocation is more complete, this margin 
begins to fall over backwards, as in the accompanying 
drawing; and in more extreme cases the patella lies Dislocation of the,,;, 
flat upon the outer side of the condyle, with its inner tella outward*, 

margin directed forwards. 

When the dislocation is partial, it is probable that neither the capsule 
nor the Ligamentum patellae usually Buffers much Laceration; bul in com- 
plete dislocations the capsule at least musl have given way more or Less. 
Norris, of Philadelphia, reports a case of partial dislocation in which the 
complication- were more serious. John Seanlin, aet. '■'>-. was admitted 
to the Pennsylvania Hospital, on the -7th of August, L839, in conse- 
quence of injuries received a short time previous by having become 
entangled in machinery. In addition to several fractures in other Limbs, 




DISLOCATIONS OF THE PATELLA. 

he was round to have a subluxation of his left patella outwards, its outer 
edge being much raised, and resting on the side of the external condyle 
of the femur, while its inner edge was depressed, and firmly fixed in the 
hollow between the condyles. The internal lateral ligament of the knee 
was ruptured, allowing the head of the tibia to be moved considerably 
outwards. A depression existed, also., between the tubercle of the tibia 
and the lower end of the patella, at the middle and inner side of the 
knee, evidently produced by a rupture of the ligamentum patellae in 
nearly its whole extent. There was almost no swelling, and the limb 
was moderately flexed. By firm pressure the patella could be restored 
to position, but as soon as the hand was removed it returned to its orig- 
inal position. At the end of two months " a good degree of motion 
existed at the knee-joint, which was in no way inflamed or painful.'* 1 

M. Berger has gathered six examples of ancient complete dislocations 
outwards, which have been examined anatomically, namely, two by Ver- 
neuil. two by Tainturier. and two by Philipeaux and Fiihrer. In each 
of these examples the patella rested upon the tuberosity of the external 
condyle, which in two cases of Philipeaux and Tainturier, had become 
articular, flattened, and covered by newly formed cartilage of consider- 
able thickness. The patella was thickened and globular in the case of 
Verneuil. It was also rather triangular than rounded in the case de- 
Bcribed by Tainturier. In Philipeaux's case it was atrophied to about 
the size of a two-franc piece. The diarthrodial cartilages in one of Ver- 
m-nil's eases, upon both the femur and tibia, were entire: the external 
condyle was flattened, and in consequence of the pressure the inter- 
condyloidean space was diminished posteriorly. Tainturier has noted a 
Bort of tortion of the femur from without inwards. In two or three of 
these cases there was observed a laceration of the internal ligaments of 
the patella, and in one of VerneuiTs cases the tendon of the vastus 
internus was torn also. 2 

Vesale, 9 Textor pere, 4 Vering, 5 Monteggia, 6 Dupuytren. 7 and Hamoir 8 
have also observed cases in which the displacement interfered but little 
with the usefulness of the limb. 

In a case seen, however, by Berard, the patient had a dislocation 
of several years' standing, and there was partial anchylosis of the knee 
in a position of semiflexion. Stromeyer and Hopfe have each met 
with a similar example. 

Fowler'' met with a case in a girl set. 21. which dated from her fifth 
year, and who was so much maimed that Dr. Fowler thought it proper. 
first, t«» divide Bubcutaneously the "patellar tendon,"' but without any 
satisfactory result. Eighteen days later he excised the patella. From 
the report of this case it must be inferred that her condition was not 
improved by this operation. 

Sympt om s. — The limb is slightly bent, but immovable: the breadth 
of the knee Lb considerably increased: the inner condyle projects un- 

1 X->rri*. Ainer. .T-mrn. Med. Sci.. Feb. 1840, vol. xxv. p. 27*3. 

rule. Die. Encve. Sci. Med., ser. 3, t. 5, p. 343. (Poinsot.) 
3 Berber, loc. cit., p. 341. l Ibid. 5 ibj<q 

paigne, op. cit., p. 906 T Ibid. a Ibi( i. 

!. Mav »;. L871. 



DISLOCATIONS OF THE PATELLA OUTWARDS. 895 

naturally, and the patella is distinctly felt upon the outer side. If the 
dislocation is partial, the outer margin of the patella forms an irregular 
sharp ridge in front of the external condyle. If it is complete, the 
inner margin presents itself in front of the external condyle, and the 
outer margin looks backwards. Uusually the patient suffers great pain 
as long as the dislocation remains unreduced. 

Watson, of New York, saw a case of complete dislocation of the patella 
outwards in a fat young lady with lax fibre, and occasioned by dancing. 
He says the knee was slightly but firmly flexed. It was reduced by very 
slight pressure with the fingers, and although some inflammation with 
effusion into the joint ensued, the use of the limb was completely re- 
stored in a week or ten days. 1 

Prognosis. — Reduction is in general easily accomplished, but a redislo- 
cation is very prone to occur. In a few examples reported of a perma- 
nent dislocation, the patients have eventually recovered the use of the 
limb in a great measure. Boyer saw four cases of this kind, in three of 
which it existed in the left leg, and had remained from infancy. The 
patellae were easily replaced, but unless confined they soon became dis- 
placed again ; not one of them found it necessary to apply for surgical 
aid, as "they suffered no great inconvenience from the dislocation, and 
it exempted them from military service." 

After reduction very little or no inflammation usually follows. Mr. 
Key, has, however, narrated a case in G-uys Hospital Reports, of death 
from suppuration in the knee-joint, following upon the reduction of an 
inward subluxation. The dislocation was produced by a fall while car- 
rying a pail, and was reduced by very gentle pressure ; but the patient, 
a, girl set. 20, although apparently in good health, was believed to be 
somewhat strumous. 2 

Treatment. — In order to relax completely the quadriceps extensor, 
by whose action chiefly the patella is held in its unnatural position, the 
body should be bent forwards, while at the same moment the leg is ex- 
tended upon the thigh and the thigh flexed upon the body. The surgeon 
will accomplish these indications in the most simple manner by placing 
the patient in a chair and then lifting the foot upon his own shoulder, as 
he kneels or sits before him. Sometimes the patella will resume its 
position at once when this manoeuvre is adopted; but if it does not, 
slight lateral pressure, made with the fingers, will generally be found 
sufficient to accomplish the reduction. 

A man, ?et. 27, was sitting on a box, and in jumping off tripped hi in- 
self with his right leg, causing a partial dislocation of the patella of tin- 
left leg outwards. Half an hour after the receipt of the injury I found 
him sitting with the knee bent, and in great pain. The pajtella lay upon 
the outer half of the articular surface, with it- outer margin ;i little tilted 
upwards. Lifting the leg and thigh to a right angle with the body, and 
making very slight pressure upon the outer margin of the patella, il im- 
mediately resumed it- place. Very little inflammation ensued. 

In some instances, where other means have failed, the reduction has 

1 Watson, New York Journ. Bled., vol. i. p. 806. 

-it., vol. i. p 



896 DISLOCATIONS OF THE PATELLA. 

been effected by violent flexion and extension of the knee, aided by 
lateral pressure. 

I have already mentioned, when speaking of dislocation into the fora- 
men thyroideum, the case of N. Smith, in whose person I found at the 
Bame moment a dislocation of the thigh, a subluxation outwards of the 
tibia, and a complete outward dislocation of the corresponding patella. 
This was occasioned by a fall from a height upon the inside of the knee. 
1 reduced the tibia first, and then easily replaced the patella by lifting 
the lei: and pushing with my fingers against its outer margin. 

In many cases the patients themselves have reduced the dislocation 
immediately, and the surgeon is only consulted in relation to the after- 
treatment. Liston says that this is so constantly the fact, or else such 
dislocations are really so rare, that it has never happened to him to have 
an opportunity of reducing any form of dislocation of the patella. 

A young gentleman, sst. 25, residing in Somerset, N. Y., called upon 
me in consequence of having discovered a floating cartilage m his knee- 
joint. His account of the matter was that on the 1st of February, 1858, 
he was kicked by a cow upon the outside of the right leg, about six 
inches below the knee, and that he immediately found the patella dislo- 
cated outwards. After several efforts, he finally succeeded in reducing 
it himself. His knee soon became greatly swollen, so that for five weeks 
lie was unable to walk, and he has been more or less lame to this time. 
Six months after the accident he discovered a floating cartilage on the 
inside of the patella, about one inch in diameter, which occasionally slips 
between the joint surfaces, and suddenly trips him up. 

In 1870 M. Duplay 1 found in the Hospital Beaujon, a man get. 25, 
with an incomplete external dislocation of the patella, of recent occur- 
rence, and which he was unable to reduce by any of the ordinary methods. 
I>uplay then, the patient being chloroformed, introduced through the 
integument, and fastened firmly into the projecting portion of the 
patella a strong hook, by pulling upon which the bone was restored to 
position. 

In a case of recent dislocation wdiich proved to be irreducible, Moreau 2 
opened the capsule and passed an elevator between the patella and the 
femur, but he was then unable to reduce the dislocation. "The consecu- 
tive accidents were formidable." 

It Beema proper to repeat here what has been said before, that the 
facta of modern Burgery do not justify the assumption occasionally made 
by my contemporaries, that the knee-joint can be invaded with impunity, 
and that "formidable accidents" are not likely to ensue despite ahtisep- 
t !<•». drainage and the other appliances of modern surgery. 

?: 2. Dislocations of the Patella Inwards. 

The existence of :( complete inward dislocation has been denied by 
Nelaton, Strenbel, and questioned by Malgaigne. 

lay, Bull. S.»c. de Chirur^. de Paris 1870. 
- Moreau, Poinsot, op. cit., p. 1121. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 



897 




Dislocation of the 
patella inwards. 



One example of incomplete dislocation has been described anatomically 
by Key, and which has been already referred to as having terminated in 
death from suppurative arthritis. In this case there 
were found laceration of the outer portion of the cap- FlG - g 64- 

sule. and a partial rupture of the tendon of the vastus 
externus. 

Causes. — They are occasioned generally by direct 
blows received upon the outer margin of the patella. 

The symptoms and treatment will be the same as 
in dislocations outwards, except so far as these must 
necessarily vary from the opposite position of the 
patella. 

§ 3. Dislocations of the Patella upon its Axis, 
(a) Vertical. 

Syn. — ''Semi-rotation: - ' Miller. •• Luxation Yerticale:" 
Malgaigne. 

These accidents, of which I have found recorded 
about twenty-four examples — and one additional case 
has been seen by myself — seem to be the result of the 
same causes which produce lateral dislocations ; and. 
indeed, they may be regarded as only exaggerated forms of incomplete 
lateral dislocations. In these latter accidents, as we have already 
noticed, the external or the internal margin of the patella, according as 
the subluxation is to the outer or inner side, is thrown more or less ob- 
liquely forwards ; a position into which it is carried partly by the pecu- 
liar form of the articulating surfaces, and partly by the action of the 
vasti and rectus femoris muscles. If now these muscles were to contract 
suddenly and violently, and the return of the patella to its normal posi- 
tion were prevented by the lodgement of one of its margins in the inter- 
condyloidean fossa, the other or free margin would be compelled to rise 
until it became perpendicular to the limb, or it might perhaps even 
become completely reversed. 

iptoms. — The signs of the accident are such as to render an error 
in the diagnosis almost impossible. The limb is generally found forcibly 
rionally it is in a position of moderate flexion, bur the pro- 
jection of the aharp bonier of the patella directly forwards under the 
skin is itself sufficient to determine the true nature of the injury. 

Treatment. — Reduction may be effected by the same manoeuvres which 
I have recommended in lateral dislocation-: but If these measures do not 
succeed, we may direct the patient to make a violent effort himself to flex 
and extend the limb, or the surgeon may force the limb into flexion and 
rion alternately, or he may rotate the tibia upon the femur, and 
then flex. Finally, he ought to make use of lateral pressure also, upon 
both margins of the nprighl patella, but in opposite directions. 

In all cases it would be advisable to put the patient under the influence 
of an anaesthetic before attempting reduction. In n case reported by 
Dr. H. Hunt, of Beloit the reduction occurred spontaneously as soon u 

:,: 



DISLOCATIONS OF THE PATELLA. 

the patient was chloroformed, although it had resisted all the efforts 
previously made. 1 

Watson, of New York, has related the following example of rotation 
of the patella upon its inner margin ("Luxation Verticale Externe," 
Mah.) : 

Henry Burton, aged about thirty-five years, of rather slender frame 
while titling on horseback in a crowd, received a blow upon his knee 
from a horse ridden by another person. When seen by Dr. Watson, 
Boon after the accident, the leg was perfectly straight, but could be 
flexed to about an angle of 140° without causing pain. " The patella 
appeared to be slightly drawn up, and it was twisted upon its axis, pre- 
senting its outer edge, in a prominent hard line, in front of the knee; 
its inner edge was resting either in the groove between the condyles of 
the femur, upon which its posterior face should naturally play, or in the 
small depression on the anterior face of the femur, immediately above 
this groove. The anterior surface of the patella was turned inwards, its 
posterior surface outwards, and it rested nearly at right angles with its 
natural position. Its upper and lower attachments were both preserved, 
and could be distinctly felt; and a sort of band appeared to pass from 
its nnder, or, as it now lay, its outer face, inwards to the deeper portion 
of the knee-joint. This band, as I conceived, was caused either by the 
tension of the capsular ligament, or by the rupture of its edge, as it 
passes from the outer side of the patella. The position of the bone 
was so well marked that no one at all acquainted with the anatomy of 
the part could mistake the nature of the accident. 

" With the leg extended, and the anterior muscles of the thigh forced 
downwards as much as possible, pressure was made upon the patella, 
with the expectation of forcing down its prominent edge. The effort 
was followed only by an increase of pain, the bone remaining perma- 
nently fixed. Another attempt was made to cant its posterior edge 
inwards, and to bring its anterior edge outw r ards, without pressing against 
the condyles of the femur, by forcing the head of a key against the pos- 
terior, now the outer, face of the patella (using this as a fulcrum), and 
pressing the prominent edge of the bone toward the outer condyle. This 
manoeuvre nave him no pain, but was as fruitless in its result as the 
other. At length the knee was forcibly bent and immediately straight- 
ened again : and then, by canting the patella as before, and pushing it 
slightly downwards and inwards, it sprung with a sudden snap into its 
proper position." 2 

Dr. Joseph P. Gazzam, of Pittsburg, Pa., has met with a similar case. 
On the 10th of September, 1842, James Porter was thrown while wrest- 
ling, and immediately found himself unable to rise. Dr. Gazzam saw 
him about an hour after the accident, and found the patella of the right 
Leg dislocated on its axis, and resting on its inner edge in the groove 
between tlie condyles of the femur. Dr. G. proceeded to attempt reduc- 
tion, but failed, after having made repeated trials by lifting the limb 
toward the body and by pressure in opposite directions. In consultation 

1 H. Hunt, M.D.. The Medical Record, April 1, 1873. 

2 Watson, N<u York Journ. Med., Oct. 1839, p. 302. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 899 

with Dr. Addison, it was now determined to divide the ligamentuni 
patella?, which was done by introducing beneath the skin a narrow- 
bladed knife, and cutting close to the tubercle of the tibia. Again the 
attempts at reduction were renewed, but without success. The patella 
could be moved on its edge more freely than before the cutting, but 
resisted every effort to replace it. The patient was now bled in the 
erect posture, and until the approach of syncope, but to no purpose. ( )n 
the following morning it was determined to adopt, with some modifica- 
tion, the mode practised so successfully by Dr. Watson. " The thigh 
was strongly flexed," says Dr. Gazzam, '"on the pelvis, and the heel 
elevated. Then the leg was flexed steadily and forcibly on the thigh, 
and suddenly straightened. At the moment of straightening the leg. I 
pressed very strongly against the lower edge of the patella from without, 
with the head of a door-key well wrapped, while Dr. Addison pressed 
with both thumbs against the upper edge of the bone toward the external 
condyle. On the fourth trial this manoeuvre succeeded, the bone spring- 
ing into its place with a snap." Recovery was uninterrupted, and two 
or three months after, the patient had the complete use of his limb. 1 

The following case is reported by Dr. S. F. Morris. New York : 

"Mr. B.. aged 27, of slender build, while playing at ball, in en- 
deavoring to strike the ball had to jump up and turn partially round, 
when, on resuming his former position, he fell, his leg refusing to bend. 
He appreciated the nature of his injury, and. with the aid of the men in 
the store, endeavored to ' push it back.' Failing in this, surgical aid was 
sought, but, despite three attempts at reduction, the patella remained 
displaced. He was then taken to his home. 

u I saw him about two hours after the accident. He complained of 
severe pain when any manipulation was made. The leg was perfectly 
straight. The patella was firmly wedged (its outer edge) in the inter- 
condyloid fossa ; its anterior surface looking outwards and slightly down- 
wards, its posterior face looking inwards and upwards. The prominence 
of the edge of the patella, thus twisting on its longitudinal axis, left no 
doubt as to the diagnosis. 

" No attempt was made at reduction by me until the patient was 
etherized, when, assisted by Dr. C. M. Bell, of this city, it was easily 
performed in the following manner : The leg was raised from the bed, the 
thigh flexed on the pelvis. Dr. Bell then placed his thumb, as a fulcrum, 
beneath the under (posterior) surface of the patella, and pressed on the 
upper (anterior) surface; at the same time I slightly flexed, then suddenly 
extended and rotated the leg inward-. The patella immediately resumed 
it- natural position." 3 

Dr. Sternberg. Assistant Surgeon ('. S. A., has also published :i case 
in the Medical <iml Surgical Reporter, reduced readily when the patient 
was under the influence <»f chloroform. I am unable to find the date of 
the record, but I think it was in 1869. 

The following ease i- reported by Gr. P. Davis, M.D., of Hartford, Conn. 

••A few weeks ago 1 was summoned to a nurse girl, who was reported 

to have 'put her knee oul of joint.' On entering the room, I round the 

1 Gazzam, Amer. Journ M - vol. \\\\.. April, - 
- Horns, T: M I k ; M I " - 



900 1'IsLOCATlONS OF THE PATELLA. 

patient Laying on her face, both legs extended, and the left foot pointing 
toward its fellow. 

•• On turning the patient upon her back, the left patella was plainly 
seen in a eondition of "vertical " displacement, i. e., turned upon its 
inner edge, BO that its upper surface looked toward the opposite knee. 
It was rigidly fixed, and the limb was entirely helpless. 

•• I learned that while sitting upon the floor, playing with the baby 
under her charge, she suddenly reached forwards, at the same time twist- 
ing her body partly around, in order to seize the child, who was a little 
out of her reach, and who, she feared, was about to fall. She immedi- 
ately became conscious that an accident had befallen her knee. 

•• The patient was etherized as she lay upon the floor. The whole limb 
was then elevated by an assistant, so as to relax the muscles in front of 
the thigh, and, by forcibly crowding down these muscles toward the knee 
with one hand, manipulating the patella at the same time with the other, 
reduction was effected with the utmost ease." 1 

April 1, 1875, through the courtesy of Dr. A. R. Robinson and of 
Prof. S. B. Ward, of New York, I was permitted to see a case of " semi- 
rotation " of the patella. The accident had happened the day before, in 
the person of Susan Newman, set. 31, a muscular Scotch woman, while 
wrestling. Dr. Robinson being called, attempted reduction by pressure 
and by other means, but without success. About seventeen hours after 
the accident I found her in bed with the left leg extended upon the thigh, 
and the patella standing upon its inner margin, which rested in the inter- 
condyloid notch. The patella was not vertical, but leaned over toward 
the outside of the knee. 

While placing her under the influence of chloroform, she bent her leg 
to a right angle, but the patella continued to occupy its abnormal posi- 
tion. When completely under its influence, Dr. Ward extended and 
flexed the leg with no result. He then tilted the patella down until it 
lay flat upon the outer condyle (this was the position it took also when, 
being partially chloroformed, she flexed the leg); and after a second 
attempt, with moderate pressure against the outer margin of the patella, 
it suddenly resumed its position. None of the tendinous or muscular 
attachments were ruptured. 

Dr. J. M. Boyd, of Thorntown, Indiana, reports a case of vertical 
dislocation, the patella resting upon its internal margin, in a negro 38 
years old, and which was caused by muscular " spasms." Attempts 
were immediately made by a surgeon to reduce it, but without success. 
Subsequently Dr. Boyd tried also and failed; but at the end of two 
w.ck- the muscular spasms returned, and before Dr. Boyd could reach 
the house the hone had resumed its position spontaneously. 2 Malgaigne 
has reported, also, a case in the G-azette Medicale, for 1836, in which 
reduction was accomplished spontaneously during an attempt made by the 
patient to walk. The same writer refers to a case reduced under the 
influence of chloroform. Mr. Flower (Holmes's Surgery) records a 
similar case. 

I" a case of the same kind, published originally in Rust's Magazine, 

1 Davis, The Med. Record, Dec. 1, 1874. 

' Boyd, Western Journ. Med., May, 1868, p. 275, and June, 1868, p. 341. 



DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 901 

and which is copied at length by Mr, B. Cooper in his edition of Sir 
Astley's great work, the reduction was found impossible, notwithstanding 

the surgeon finally had the temerity to sever completely the tendon of the 
quadriceps extensor, and the ligamentum patellae. Extensive suppura- 
tion followed, under which the poor fellow finally sank and died. 

Dr. Alexander N. Dougherty, of Newark, N. J., has reported a case 
in which he succeeded in effecting reduction by pressure made with his 
hand while the limb was in an extended position, and without anaes- 
thesia. 1 

Dr. "Win. B. Bradner. of Warwick, Orange Co., N. Y., reports a case 
occurring in a boy, set. 9 years, caused by a fall in wrestling. The limb 
— the right — was slightly flexed. Dr. Bradner describes the reduction 
as follows : " To relieve the strain upon the patella preparatory to re- 
duction, I seized his ankle in my right hand, and raised it from the bed ; 
then I placed my left hand over the patella and grasped the knee ; then 
by depressing the knee forcibly with one hand, and raising the heel with 
the other. I found it a very easy matter to rotate the patella to its normal 
bed." The boy recovered at once the complete use of his limb. 2 

Dr. W. R. Cluness, of Sacramento, Cal., reports a case reduced by 
him in the extended position and by lateral pressure. 3 

In a case occurring in a lady, 36 years of age, solely from muscular 
action, the reduction was easily effected by Blair D. Taylor, Assistant 
Surgeon U. S. A., by bending the knee as much as possible, and then 
suddenly straightening it, while at the same moment the patella was 
pressed firmly over. 4 

In two cases Cuynat 5 has followed successfully the example of Moreau, 
already referred to in connection with dislocations outwards, by intro- 
ducing an elevator through an incision; and without any of the "formi- 
dable " accidents which ensued in Moreau's case. 

(b) Complete Version. 

Syn. — u Renversement ;" Malgaigne. 

In the earlier editions of this treatise, this dislocation is referred t<» as 
representing the most advanced or complete form of patellar rotation : 
but I have decided hereafter to speak of partial version (vertical) and 
complete version as two distinct forms. 

Complete version, like partial version, presents two varieties, aamely, 
version from without inwards and version from within outward*. 

Malgaigne 6 refer- to ;i case reported by J. Sue in \~~>1. of version 
from without inwards, which was not however complete, and which was 

unaccompanied with ;i rupture of tie- ligaments. Later, Bruyerea is re- 
ported to have said to tie- Royal Academy of Surgeons thai he had seen 
a complete version of the patella, and without rupture of the ligaments. 

1 Dougherty, The Med. Record, Dec. 80, 1876, | 

2 Bradner, Ibid., Jan. 20, 1877 

3 Cluness, 11. id.. Jan. 27, 1877. 

* Tavlor, Ibid., May 26, 1-77 p 

6 Cuynat, Becuil de lieni. de Me"d , de Pbara CI ^ 6, t. 18 

6 Sue. Malg it., vol. 2, p 



902 DISLOCATIONS OF THE PATELLA. 

( lastara ' reports a case of complete version from within outwards, in a 
girl of 1" years; the tendon and ligamentum patellae were twisted into 
a cord. Reduction was easily effected by seizing the patella between the 
thumb and index finger, and by rotation from behind forwards, and from 
without inwards made slowly and gently. 

Berger cites a similar case as having been published by Gaulke 2 in a 
girl of IT years, who had fallen from a horse. Gaulke, who did not see 
the case until after ten days, was at first unable to effect reduction, even 
when the patient was under the influence of chloroform. On the following 
day (Jaulke procured a carpenter's wooden vice, and enclosing in its grasp 
the internal condyle and the outer margin of the patella, he succeeded, 
after several ineffectual efforts, in restoring it to position ; but not with- 
out some laceration of the integuments. Recovery took place speedily, 
and without any inflammatory accidents. 

§ 4. Dislocations of the Patella Upwards. 

Occasionally the ligamentum patellae has been found so much elongated 
and relaxed, as to permit the patella to glide upwards upon the front of 
the femur. Heister and Ravaton have each seen an example in which 
a displacement from this cause existed to the extent of three inches. It 
is much more common, however, to meet with this dislocation as a result 
of a rupture of the ligamentum patellae, as the following example will 
illustrate : 

On the 18th of Dec. 1850, Dennis Mullards, aet. 50, was admitted to 
the surgical wards of the Buffalo Hospital of the Sisters of Charity. 
While at work on the same day, he had slipped and fallen, with his 
knee forcibly flexed under his body. I found the ligament of the patella 
torn asunder, and the patella drawn up two or three inches upon the 
front of the thigh. We applied at once the dressings used by me for a 
broken patella, and were able to bring the bone down completely to its 
place. Three weeks from the time of the receipt of the injury the dress- 
ings were removed, and the patella was found to be nearly but not quite 
in its original place. From this time we commenced to move the joint: 
in about ten days more he left the hospital, and I lost sight of him, so 
that T am unable to speak more definitely of the result. 

Mrs. Fanny Neill, ast. 45, fell upon her right knee, causing a lacerated 
wound and a rupture of the ligamentum patellae. Four years later, Oct. 
28, l ss <). I found the patella one and a half inches above its natural 
position. She was able to walk up and down stairs without difficulty, 
and while sitting she could lift the leg and straighten it upon the thigh 
perfectly. 

The following case is unique: Miss M. E. Bracket was thrown in 
alighting from a stage, and, on consulting a druggist, was told that she 
h;.d ruptured the ligamentum patellae. Some time later, Oct. 20, 1880, 
she consulted me, when I found the lower edge of the left patella tilted 
forwards, with a manifest depression below the patella caused by the ab- 

1 astara, Mal^aigne. op. cit, p. 921. 
Gaulke, I)<ut.<ch. Klin., vol. 2, 1863. 



DISLOCATIONS OF THE PATELLA UPWARDS. 903 

sence of the anterior, or most superficial fasciculus of the ligament. The 
posterior fasciculus, attached to the posterior margin of the patella, could 
be distinctly felt, and seemed to be normal in length and breadth. In 
walking the knee is apt to give way suddenly, as happens, when there is 
a floating cartilage in the joint. I directed her to wear an elastic knee- 
cap : but she omitted to do this except occasionally, and when she again 
consulted me, about one year later, there was no appreciable change in 
the condition of the limb. 

In February, 1869, Dr. George H. Smith consulted me in relation to 
a gentleman who had ruptured the ligament of the patella in both legs, a 
little more than a year before, by catching his heel in descending from 
a carriage: the ligaments giving way in the powerful muscular effort 
which he made to prevent himself from falling. 

Treated upon a single inclined plane in the same manner that I have 
recommended for a fractured patella, at the end of five weeks the patellae 
were in place and the ligaments reunited. After walking about one 
month upon crutches he caught the heel of his right foot again and again 
ruptured the ligament of the patella in the same leg. A similar plan of 
treatment failed to accomplish anything, and when he consulted me the 
patella was displaced three inches upwards. He could raise the leg slowly 
to a position of extension while sitting, and was able to walk four or five 
miles a day. 

Gibson has recorded a similar case, in which both patella? were dislo- 
cated upwards by a rupture of the ligaments, occasioned by the exercise 
of leaping. He recovered the use of his limbs almost completely. 1 



(For examples of rupture of the quadriceps femoris, which some 
writers have incorrectly named Dislocations of the Patella Downwards, 
see Velpeau'a Surgery, 1st Amer. ed., vol. i. p. 422; New York Med. 
Times. April 6, 1861, p. 226, and two cases reported by myself in the 
same volume of the Med. Times: Demarquay, Mem. Rup. Tend, du Tri- 
ceps. Gaz. Med.. Paris, 1842: Renouard, Arch. Gen. de Med., Ber. 4. 
t. 15, ]>. 101 : Binet, Rup. tend, triceps, <t du Lig. Rotulien, Arch. 
Gren. Med., ser. 5, t. 2, p. 687, 1858; Adam-. Case of Rupture of the 
Tendons of both Recti Fern., Lancet. 1861, vol. 2. p. 22<i: Lorinser, 
Wiener Med. Woe],.. 1869, Bd. 19, 8. 27 : Berger, Art. Rotule, Die. Enc. 
Sci. Med.. Ber. 3, t. 5, p. 330.) 

1 Gibson, Surgery, v.,] i. }.. 896, 6th ed. 



904 



I) IS I, OC AT IONS OF THE HEAD OF THE TIBIA. 



CHAPTER XIX. 



DISLOCATIONS OF THE II FAD OF THE TIBIA (FEMORO-TIBI AL). 

San. — •' Tibia upon the femur;" "dislocations of the leg." 

In consequence of the great size and irregularity of the articular 
surfaces between the tibia and femur, together with the remarkable num- 
ber and strength of the ligaments which bind the two bones together, 
dislocations at this joint are exceedingly rare. They are known to take 
pi ace, however, in four principal directions, namely, backwards, forwards, 
inwards, and outwards. A dislocation may also occur in either of the 
diagonals between these points, that is, antero-laterally or postero-laterally, 
or the tibia may be dislocated by rotation. Dislocations of the head of 
the tibia may be either complete or incomplete. Velpeau found upon 
record thirteen examples of complete dislocations forwards and eight 
backwards, but not one of a complete lateral dislocation. Velpeau 
thought, also, that the antero-posterior dislocations were always complete, 
but Malgaigne has shown that this opinion is erroneous. 

§ 1. Dislocations of the Head of the Tibia Backwards. 

Si/mptoms. — The head of the tibia is felt in the popliteal space ; and, 
if the dislocation is complete, the pressure upon the popliteal nerve be- 
comes excessively painful. 

A marked depression exists in front, immediately below the patella, 
and especially upon the sides of the ligamentum patellae ; the condyles of 
the femur project strongly in front ; the leg may be 
not at all (incomplete) or only slightly shortened, or 
the shortening may amount to one inch or more ; 
and usually it is in a position of extreme extension, 
or thrown forwards from the line of the axis of the 
femur ; but its position has been found to vary 
greatly in different cases, the limb being some- 
times very much flexed, and in others very slightly 
flexed, or perfectly straight. 

Pathological Anatomy. — The posterior liga- 
ment of the joint is torn; the muscles of the 
ham are stretched; the popliteal nerves and 
vessels compressed; and the head of the tibia 
either rests partly upon the posterior half of the 
lower articulating surface of the femur (incom- 
plete), or it passes up and rests only against its 
posterior articulating surface, which in this di- 
rection extends an inch or more upwards. If 
the dislocation is complete, the crucial liga- 
ments are also torn, and all the parts about the 
joint Buffer extensive injury from stretching, laceration, or compression. 



Fig. 365 




Complete dislocation of 
head of tibia backwards. 



DISLOCATIONS OF HEAD OF TIBIA BACKWARDS. 905 

Prognosis. — Malgaigne has seen three examples of incomplete back- 
ward dislocations which were not reduced, and neither of the persons was 
very greatly maimed in consequence. One walked with crutches after 
three or four days, and with a cane after about fiye weeks. Another 
did not leaye his bed under one month, and it was nearly one year 
before he could lay aside his crutches; but both of them were finally 
able to walk at least twelve leagues per day. Malgaigne informs us, 
howeyer. that in a similar case seen by Lassus, the patient was confined to 
his bed two years, although he finally recovered a tolerable use of his limb. 

If the reduction is promptly effected, the limb kept perfectly quiet a 
sufficient length of time, and in other respects properly managed, not 
much inflammation need generally be anticipated, and the limb may 
suffer in the end very little if any maiming. 

Treatment. — It will be proper, at first, to attempt the reduction by 
simple manipulation, as this is often found to succeed when the disloca- 
tion is recent and incomplete, and especially when the system is greatly 
depressed by the shock of the injury. If the dislocation is complete, 
however, we can hardly anticipate success without the application of 
some extending force. 

In the employment of manipulation we ought to be governed at first 
by the same rule which we have found so generally applicable in dislo- 
cations of the femur, namely, to carry the limb in those directions in 
which it will move easily, or without the application of much force. If 
this fails, we may at once resort to forced flexion alternating with ex- 
tension : rotating or rocking the limb also occasionally from one side to 
the other, while at the same moment strong pressure is made upon the 
projecting bones at the knee-joint in opposite directions, or in the direc- 
tion of the articulation. 

Finally, it may be necessary to resort to extension, made by means of 
a lacque, or by the hands of strong assistants, above the ankle, always at 
first in the direction of the axis of the tibia; the counter-extending band 
being applied to the perineum if the leg is straight, but to the lower and 
back part of the thigh if the leg is flexed. 

A very convenient mode of making extension, where we wish to apply 
more than usual force, is to lay the whole limb over a firm double-in- 
clined plane, or fracture-splint, securing the thigh to the thigh-piece 
witli a roller, and making the extension with the screw attached to the 
foot-board. This method, however, while it enables as to use great force 
in the extension, prevents the surgeon from employing, at the same time, 
those flexions, extensions, and other manipulations, upon which success 
so often depends. 

Dr. James Carmichael has reported a case in which reduction was 
effected easily by flexion, when traction failed. 1 

Mr. Rose has related, in the Provincial Med.Jvurnaloi dime II, 1 s 12, 
a characteristic example of this accident, excepl that the patella bad also 
suffered a lateral displacement, presenting the usual favorable termination. 

A woman was standing upon a low ladder, when a carriage driven furi- 
ously came in contact with it. and precipitated her to the ground. Mr. 
Rose, who saw her almost immediately, found the tibia completely dislo- 

] New York M 



906 



DISLOCATIONS OF THE HEAD OF THE TIBIA. 



cated at the knee, the head being driven behind the condyles of the femur 
into the ham, with the patella thrown to the outside of the external con- 
dyle, and the leg in a state of fixed extension. Immediately, and without 
difficulty, the hones were restored by applying one hand to the patella, the 
other to the back of the upper portion of the tibia, and simultaneously 
pulling and pushing those bones toward their natural positions. The 
patient was then removed to a bed, and by the diligent use of antiphlogistic 
remedies inflammation was kept in check, and the case reached a favor- 
able termination without one untoward symptom. After the lapse of only 
a few weeks, she had completely recovered the use of the knee-joint. 1 

Dr. Walsham communicated a case to Sir Astley Cooper, in which 
the dislocation was not only complete, but the tendon of the quadriceps 
cxnnsor was ruptured. The leg was bent forwards. The reduction 
was accomplished very easily by extension made with the hands by four 
men, in the line of the axis of the limb. In about one month this man. 
began to walk with crutches, but he was not perfectly recovered until 
after five months ; at which time the crutches were finally laid aside. 2 

^ 2. Dislocations of the Head of the Tibia Forwards. 

The signs of this accident are the reverse of those which belong to 
dislocations backwards. The patella, tibia, and fibula are prominent in 
front, w T hile the condyles of the femur may be felt behind, pressing 
strongly upon the muscles, nerves, and bloodvessels which occupy the 
popliteal space. In case the dislocation is complete, a shortening may 
exist to the extent of one or even three 
inches. Dr. O'Beirne, of Dublin, has men- 
tioned a case to Mr. B. Cooper, in which 
the shortening was three inches and a half, 
and Mr. Mayo has seen one example in 
which the dislocated limb was " fully four 
inches" shorter than the other. 3 

In consequence of the pressure upon the 
popliteal artery, the pulsations in the 
branches below are frequently interrupted, 
and in one instance this pressure w T as suf- 
ficient to produce finally a dry gangrene. 

Dr. Gorde relates a case in the Bulletin 
de Therapeutique, occurring in a woman 
nearly sixty years old. This woman was 
returning home at night with a heavy bur- 
den, and in a state of intoxication, when 
she stepped into a ditch as deep as up to 
the middle of her thighs. The body was 
thrown forwards by the fall, while the feet 
-truck ;it the bottom of the ditch: the whole force of the impulse being 
sustained by tlie thighs. The lower end of the femur was found driven 



Fig. 366. 




Subluxation >>{ the bead of the 
tibia forwards. 



\iiim\ Journ. Med. Bci., vol. xxxi. p. 216. 
iham, sir A. Cooper on Disloc, etc., 2d. Lond. ed., p. 188. 
I'- Cooper - '■'!. of sic Astley Cooper on Disloc. etc.. pp. 214, 215. 



DISLOCATIONS OF HEAD OF TIBIA FORWARDS. 907 

downwards and backwards, and lodged under the muscles of the calf of 
the leg : the limb being shortened three inches. Reduction was promptly 
effected, and without inflicting any pain of which the patient complained. 
In six weeks the patient was cured. l 

Mr. Toogood has reported also, in the Provincial Medical Journal of 
June 18, 1842, an example of complete dislocation in this direction, 
in which the appearance was so dreadful, that Mr. Toogood at first de- 
spaired of being able to reduce it ; but by directing two men to make 
counter-extension while he made extension, the reduction was immedi- 
ately effected. At the end of one month the patient was able to leave 
his bed ; and sixteen years after, Dr. Toogood saw him walking " with 
very little lameness." 2 Parker, of Liverpool, has reported another ex- 
ample in the London and Edinburgh Monthly Journal for December, 
1*42. which was occasioned by the fall of a heavy spar upon a man's 
back, and the consequent violent bending of the knee under his body. 
In this case the limb was slightly flexed, and the patella was loose 
and floating. The reduction was effected without much difficulty by ex- 
tension and counter-extension made by two men, while the operator, 
placing his knee in the ham of the patient, attempted to bring the leg to 
a right angle with the thigh. 3 

B. Cooper, Malgaigne, Little, 4 and others, have recorded examples of 
this accident. 

March 9, 1865, Hiram Wescott, of Sandy Cove, Nova Scotia, set. 45, 
was caught by his sled, drawn by horses, in such a way that a beam 
pressed against the front and lower end of the femur while the heel was 
caught and arrested by a stump. The foot was thrown forwards and 
the upper end of the tibia completely dislocated in the same direction. 
It was at once reduced by a person who was present, but on attempting 
to use the leg in walking it was redislocated immediately. Mr. J. H. 
Harris, medical student, found the limb soon after completely dislocated, 
with the leg thrown forwards in the position of dorsal flexion about 40°. 
The tendons of the hamstring muscles were not ruptured, but had slid 
forwards past the condyles of the femur. There was no external wound. 
Reduction was easily accomplished by simple extension. Pasteboard 
splints were then applied. On the third day the knee was considerably 
swollen, and some ecchymosis existed about the popliteal region. On 
the fifth day these symptoms had much Increased; Mr. Harris then 
applied extension to the foot, with the aid of adhesive plaster, pulley and 
weights, and by elevating the foot of the bed. The amount of extension 
employed was 9 lbs. This gave immediate relief to the pain, and was 
continued until the inflammation subsided. His recovery was Bteady, 
and in four months he walked with crutches or a cane 

In 1864 a similar dislocation was presented al the Brooklyn City 
Hospital, in which reduction having been practised, the patienl died. 
The case is reported very fully by I>r. Le Roy M. Yale. 8 

Dr. White, of Buffalo, invited me to see with him a lad, eet L0, 

1 Goide, Arner. Journ. If ed. Si . vol. wi. p. 226, M 

2 Toogood, Amer. Journ. Med. Sci., vol. xw\. p. 166 B5. Parker, [bid. 
* Lit' : Med. Times, Aug. 17. 1861 

Yale, N"< Fork Journ. Med., vol. ii p. 124, Nov. 1866 



908 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

whose til>i;i had been partially dislocated forwards eight weeks before, by 
a boy having hit the top of his knee with his head, while they were at 
play. His father, himself a physician, residing near town, reduced the 
limb very easily, by extension made with his own hands, and by pressing 
upon the projecting hones. Violent inflammation ensued, but at the time 
when 1 saw him, the knee was free from soreness or swelling, and the 
motions of the joint were nearly restored. 

Dr. Charles S. Downes, of Mclndoe's Falls, Vt., has sent me the fol- 
lowing account of a ease which occurred in his own practice. October, 
L861, Mrs. H., a robust young married woman, aged about 20 years, 
was driving a young horse and holding her infant in her arms, when the 
horse ran and she was thrown out. One of her legs being caught in the 
wheel, she was carried over three or four times in its revolutions before 
she became disengaged, holding meanwhile upon her infant with such 
firmness that it suffered no harm. 

A few hours later Dr. Downes and Dr. Burton found a complete dis- 
location of the tibia and fibula forwards, and the lower end of the femur 
could be felt under the muscles of the calf of the leg. The limb was 
shortened four inches and a half. The patella lay loosely in front of the 
femur, with its lower margin tilted forwards. 

The patient was laid upon a bed, and a perineal band made fast to one 
of the posts, while a lacque was placed upon the foot and attached to a 
rope folded upon itself and forming a pulley or "Spanish windlass," such 
as is described at page 827. In this way the reduction was speedily 
and easily accomplished. Hot fomentations were subsequently applied 
for several days, the limb being kept perfectly at rest. In about three 
months she was able to do her own housework, and in a short time after 
all traces of her accident had disappeared. 

The following account of a case was sent to me by my young friend, 
\h-. Ah.nzo Pettit, of Elizabethport, N. J.: 

"Joseph McGuire, laborer, set. 26, was stealing a ride upon a freight 
train upon the Central Railroad of New Jersey, on the evening of June 
19, 1*74. He was sitting upon the platform of the car, with his feet 
upon the platform of the next car, his legs extended. The train slacking 
up at ;i station, before he had time to bend his knees, the cars came 
together and pushed the head of the left tibia upwards upon the femur. 

'" 1 Baw him about half* an hour after the accident, and found a com- 
plete dislocation of tie- head of the tibia, with the patella forwards upon 
the femur. The leg was slightly flexed, and shortened two and a half 
inches. 1 succeeded in reducing it easily without assistance, or the use 
of anaesthetics, by grasping the leg with the left hand, the right being 
in the popliteal -pace, making moderate extension and flexion, and press- 
ing upon the condyles of the femur. There was considerable swelling 
and inflammation, hut they yielded under the use of refrigerant lotions. 
The leg was kept extended for three weeks, during which time he suf- 
fered tin pain whatever. At the end of two weeks I began the use of 
passive motion, cautiously, and after three weeks I allowed him to begin 
t<. walk, wearing a firm elastic knee-cap. July 22d, when I last saw 
him, ho walked with a verv Blight halt, and could bend the knee about 
ad was -till improving." 



DISLOCATIONS OF HEAD OF TIBIA OUTWARDS. 



909 



§ 3. Dislocations of the Head of the Tibia Outwards. 

Occasionally, owing to a violent wrench of the knee-joint, the lateral 
ligaments upon one side or the other are ruptured, and consequently the 
joint surfaces separate somewhat from each other; or when the limb is 
moved, the head of the tibia may slide a little forwards or backwards, or 
to either side. These are not properly examples of subluxation ; nor 
should we consider as belonging to this class the accident originally de- 
scribed by Mr. Hey as an " internal derangement of the knee-joint," but 
which also by some writers has been termed " a subluxation of the knee.'" 
Of this latter accident I will take occasion hereafter to speak a little 
more particularly. 

In subluxation, properly so called, if the direction of the dislocation is 
outwards, the outer condyle of the femur rests upon the inner articu- 
lating surface of the tibia, and if the direction of the dislocation is inwards, 
the inner condyle of the femur rests upon the outer articulating surface 
of the tibia. 

The signs which characterize this accident are such as cannot easily 
be mistaken. The limb is not shortened, nor is there anything espe- 
cially diagnostic in its position, since it has been found to be sometimes 
flexed, and at other times straight; but the strong lateral projections 
made by the inner condyle of the femur on the one hand, and by the 
heads of the tibia and fibula on the other, cannot fail to inform us as to 
the true nature of the accident. 

The treatment will not differ essentially from that which has already 
been recommended in dislocation of the tibia backwards or forwards. If 
any other expedients can prove useful, they must be 
left to the judgment of the surgeon whenever the 
exigencies of the case shall demand them. 

I have already mentioned the case of X. Smith, 
who. in consequence of a fall from a window, had 
a dislocation of the right femur, tibia, and patella. 
The tibia was subluxated outwards, and the leg was 
partially flexed upon the thigh, with the toes everted. 
Bv moderate extension, made with my own hands, 
united with alternate flexion and extension, the bone 
was easily and promptly restored to its place. Hav- 
ing reduced the femur also, the limb was laid over a 
gently inclined plane made of pillows ; and cloths 
moistened with cool water were kept constantly 
applied to the knee for many days, Very little 
swelling followed the accident, and his recovery was 
rapid and complete. 

A man was received into the North London Hos- 
pital, with a partial dislocation of the tibia outward-. 
and although the knee was much swollen, the oature 
of the injury was easily determined. The knee was 
immovable, and thetoee turned outward-. Mr. Hallam, the lion-.- surgeon, 
reduced it bv extension and counter-extension made with his own hand-. 1 



Fig. 367. 




Subluxation of the head 

of the til.iii out 



Hallam, Amer Journ. M 



910 



DISLOCATIONS OF THE HEAD OF THE TIBIA. 



Mr. Pitt records a similar case in a young lady, produced by a fall 
down a flighl of stairs. It was reduced easily by extension and counter- 
extension. Inflammation followed, but it was finally controlled, and she 
regained the use of her limbs. 1 

In one ease of subluxation, mentioned by Sir Astley Cooper, and in a 
second recorded by Bransby Cooper, the recovery of the functions of the 
joint did not seem to have been so rapid; the joint remaining unstable 
and tender for a long time afterwards. 2 



Fig 368. 



^ 4, Dislocations of the Head of the Tibia Inwards. 

There is nothing peculiar in either the signs, conditions, or treatment 
of this accident, as distinguished from a dislocation outwards, to demand 
of me a special consideration. 

Sir Astley Cooper has mentioned two cases of subluxation inwards, and 
Mr. B. Cooper has added to these a third. Sir Astley remarks that in 
the first accident, the only one indeed which he had 
himself ever seen, he was struck with three circum- 
stances : first, the great deformity of the knee from 
the projection of the tibia; second, the ease with 
which the bone was reduced by direct extension ; and 
third, by the little inflammation which followed. The 
second case of which Sir Astley speaks was commu- 
nicated to him by a Mr. Richards. In this case the 
fibula was also broken, and the reduction was accom- 
plished only after extension had been made by several 
persons for half an hour. The limb became exces- 
sively swollen, and remained so for many weeks. 
Eighteen months after the accident the knee con- 
tinued somewhat stiff, and there was an unnatural 
lateral motion in the joint, from the injury which 
the ligaments had sustained. The patient referred 
to by Bransby Cooper had met with the accident by 
a fall upon the foot, with his leg bent under him ; 
and a fellow r -workman had reduced the bone by ex- 
tension and pressure. Mr. Cooper thinks that not 
only the internal lateral ligament was torn, but also 
-Mine fibres of the vastus externus and the crucial ligaments. Violent 
inflammation ensued, which did not permit him to leave the hospital until 
after about two weeks. 3 Fergusson has seen two examples of unreduced 
subluxation inwards, in both of which the patients had regained useful 
limbs. 4 

Malgaigne mentions that Boyer, Costallat, and Key had each seen one 
similar example ; and he also enumerates two additional cases of com- 
plete dislocation attended with a protrusion of the bone through an ex- 
ternal wound: in both of which the reduction was easily effected and the 
patients recovered. 8 




Subluxation of the head 
of the tibia inwards. 



1 Pitt, Ibid., vol. xxxi. p. 465. 

1 B. Cooper's ed. ofSir Astley, op. cit., pp. 111-13. 3 Ibid. 

4 Fergusson, op. cit , p. 284. 5 Malgaigne, op. cit., torn. ii. p. 956. 



HEAD OF TIBIA BACKWARDS AND OUTWARDS. 911 



§ 5 Dislocations of the Head of the Tibia Backwards and Outwards. 

In June, 1858, Henry J., of Dansville, N. Y., ret. 24, way thrown by 
an enraged bull, and his left leg, being caught under the knee by the 
horns, was twisted violently. Drs. Prior, of Dansville, and Batton, of 
Burns, were called, and found the left knee completely dislocated; the 
tibia being displaced backwards beyond the condyles of the femur, and 
also a little outwards. The foot and leg were inclined outwards. With 
the assistance of four men, extension and counter-extension were made 
in the line of the axis of the limb, and the reduction was easily accom- 
plished. Pasteboard splints, bandages, etc., were applied to maintain 
the bones in place: but the swelling came on rapidly, and in the evening 
these dressings were removed. The limb was now laid over a double- 
inclined plane carefully padded, in order to press the upper end of the 
tibia forwards, as it manifested a constant inclination to become displaced 
backwards. This apparatus was employed six weeks, with the exception 
of two or three days, during which the limb was laid upon pillows, but 
as the pillows did not sufficiently support the back of the tibia, the 
double-inclined plane was resumed. After the removal of the plane, 
during seven weeks longer, an angular splint was kept closely applied to 
the back of the limb. 

Seven months after the accident, on the 23d of January, 1854, Dr. 
Robinson, of Hornellsville, brought the gentleman to me. I found the 
l)ones displaced backwards about three-quarters of an inch, and half an 
inch outwards, or to the fibular side. This was the position of the 
bones when he was sitting with his leg bent at a right angle with the 
thigh, but when he stood erect and bore some weight upon the foot, the 
outward displacement ceased, and the backward displacement only re- 
mained. It was very easy, however, in whatever position the leg might 
be, to push the bones forwards by the hands until nearly all deformity 
had disappeared. He could flex the leg to a right angle with the thigh, 
and straighten it completely, but he could not lift the foot and leg from 
the floor while sitting with his limb extended in front of him. He was 
unable to bear sufficient weight upon his foot to use it at all in progres- 
sion, on account of the inability to fix and steady the limb, but not on 
account of any pain or soreness which it occasioned. 

It was very plain that the surgeons were not in fault for this unfor- 
tunate condition: indeed, they seem to have exercised throughout great 
ingenuity and skill in its management. 

I directed the young man to Mr. John C. Seiffert, of Buffalo, a rery 
ingenious instrument-maker, who has since succeeded, I learn, in adapting 
to his knee a mechanical contrivance which enables him to walk quite well. 

Thomas Wells, of Columbia, South Oorolina, has described a Bimilar 
accident, the tibia being dislocated outwards and backwards, which ter- 
minated fatally on the fourth day in consequence mainly of exposure, 
intemperance, and neglect to apply for surgical aid. The bones were 
never reduced, and the autopsy disclosed also a fracture of the internal 
condyle of the femur. 1 

1 Wellfl, Arner. Journ. Med. ><■]., vol. x. p. 25, M:.v. 1832. 



!»TJ I'ISLOCATIONS OF THE IIEAI' OF THE TIBIA. 



§ 6. Dislocations of the Head of the Tibia Forwards and Outwards. 

Duvivier, 1 in 1828, treated an officer who had fallen from his horse, 
causing a dislocation of the tibia forwards and outwards, which was ac- 
companied with a shortening of six inches. Reduction was effected, and 
at the end of a year the motions of the joint were only partially restored. 

In a case reported by Wathen 2 the reduction was easily effected, but 
inflammation of the joint ensued, and the cure took place with fibrous 
anchylosis. 

^ 7. Dislocations of the Head of the Tibia Forwards and Inwards. 

M. J. Cloquet 3 met with an example of simple complete dislocation of 
the head of the tibia forwards and inwards, which had existed one year, 
and upon which the patient could bear the weight of his body. This 
latter circumstance led Malgaigne to express a doubt as to whether it 
might not have been only a subluxation ; a supposition, however, which 
cannot be entertained if Cloquet was correct in saying that the limb was 
shortened one inch and a half. Gerdy 4 met with a case of complete 
dislocation, the limb being shortened half an inch, slightly flexed, and 
immobile. The popliteal artery was compressed. Reduction having been 
effected, the patient was able on the twenty-first day to walk very easily. 

In a case reported by Sir Astley Cooper the dislocation was accom- 
panied with a tearing of the integuments, and the limb was amputated. 
Dissection disclosed a large laceration of the vastus externus, and of the 
capsule and ligaments posteriorly. The lateral and crucial ligaments 
were unbroken. 

In a case seen by Malgaigne 5 the displacement was incomplete. 

W. Mulligan 6 reports a case of complete dislocation in the person of a 
man 26 years old caused by a direct blow upon the anterior and internal 
part of the thigh. The injury seemed simple and the integuments were 
intact. Reduction was effected easily by flexion, but it was then noticed 
that arterial pulsations in the foot had ceased, and a little later the ap- 
pearance of gangrene in this portion of the limb rendered amputation 
necessary. 

Treatment. — Malgaigne says " the dislocation may be reduced by 
direct extension, as in the case of outward dislocations, but it may be 
found a little more difficult; Gerdy employed three assistants, but I em- 
ployed only two. The pressure applied to the tibia by resting the femur 
upon the knee, did not prove to be sufficient," and it became necessary to 
employ ;i m<>re solid resistance, and to substitute a block of wood for the 
operator's knee. It will be remembered that Gerdy's case was a complete 
dislocation, while Malgaigne's was incomplete. 

Sir Astley experienced ^reat difficulty in the reduction; and the dis- 
location having ;it mice been reproduced, amputation was practised. 

; Duvivier, Malgaigne, from A.rch. Gen. de Med., 1829, t. 20, p. 292. 

Wathen, Poinsot, from Med. Times and Gaz., Nov. 23, 1872. 

Cloquet, Die de Med., Art.Genou. 
' Gerdy, Arch. Gen. de Med., 1835, t. 13, p. 163. 

Malgaigne, op <-it., vol. 2, p. 959. 
* Mulligan, Med. Press and circular. Sept. 15, 1875. 



INTERNAL DERANGEMENT OF THE KNEE-JOINT H13 



§ 8. Dislocations of the Head of the Tibia by Rotation. 

Rotation sometimes accompanies either of the preceding dislocations; 
but I speak now of examples in which the dislocation is by rotation 
alone. Malgaigne 1 has cited the following examples : 

In the case of Dubreuil, 2 which was presented in the service of Mal- 
gaigne himself, the leg was extended and rotated outwards until the head 
of the fibula projected in the popliteal space, and the patella, dragged by 
the tibia, was completely dislocated outwards. The dislocation was re- 
duced two hours after the accident by a single assistant, who, grasping 
the upper portion of the leg with both hands, made slight traction and 
then rotated the limb from without inwards. Nineteen months after the 
accident the knee was stiff, painful, and incapable of supporting the body. 

Boursier, 3 of Bordeaux, published an example of this form of dislocation 
which occurred in a person aet. 19. When admitted to the hospital the leg 
was slightly flexed, and rotated outwards. There was no discoloration 
or swelling. The patella was lodged upon the external condyle. At- 
tempts at reduction by extension and rotation were unsuccessful ; but on 
placing the patient under the influence of chloroform the reduction was 
easily effected by the same manoeuvres. Codman and Petrequin have 
each reported one example of outward rotation seen in autopsies. 

[Malgaigne cites also a case reported by M. Paris 4 of dislocation by 
rotation inwards, the internal condyle of the tibia resting behind the 
internal condyle of the femur. Reduction was easily effected, but a 
chronic arthritis ensued. 

^ 9. Internal Derangement of the Knee- Joint. 

Syn. — ■ Slipping of the semilunar fibro-cartilages ;" Hey. " Partial dislocation of 
the thigh-bone from the semilunar cartilages ;" Sir Astley Cooper. " Subluxation of 
the semilunar cartilages ;" Malgaigne. " Subluxation of the knee;" Erichsen. To 
these I think it proper to add, as giving rise to the same class of symptoms, " Float- 
ing cartilages in the knee-joint." 

I have already expressed the opinion that this accident is in no proper 
sense a subluxation of the knee ; and I should not, therefore, think it 
worth while to make any farther allusion to it, were it not necessary in 
order to enable the student of surgery to distinguish between the pheno- 
mena which belong to it and those which belong strictly to subluxation 
of this joint. 

Symptoms. — The patient is suddenly thrown to the ground while 
walking, as if by an instantaneous loss of power in the affected limb, this 
Lose of control over the limb being accompanied usually with sharp pain, 
referred to the region of the knee-joinl ; or he trips his toeagainsl some- 
thing in his path, and the toes becoming everted, the leg suddenly gives 
way under him; in some cases il has happened when the patient was 
turning in bed. the weight of* the bedclothes hanging upon the toes 

1 Malgaigne, op. cit., vol. 2, p 

- D ibreuil, Aol,. Gen. de M&3 . 1862, t. 80, p. 162. 

sier, Journ. de MecL, Bordeau D p. 226. 

!' s, Malgaigne, from Rev. Med. Chir.,vol 12, p. 

5* 



!U4 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

to occasion a strain and rotation outwards at the knee-joint, or it follows 
upon a subluxation of the joint, as in one example which I shall presently 
relate : or it may result from forced flexion of the knee. 

It' the patient is walking when the accident takes place, and he falls 
to the ground, he finds himself unable to move the limb, or to stand upon 
it ; but by manipulation or extension, the difficulty is, in most cases, as 
easily overcome as it occurred, when immediately the motions of the joint 
become free, and he walks off as if nothing had happened. 

When the accident has once taken place, it is afterwards exceedingly 
liable to occur from very slight causes, and eventually the knee-joint 
becomes tender and the capsule fills with synovia, indicating the existence 
of subacute synovitis. 

A young man, from Colesville, N. Y., ret. 23, consulted me, on the 
27th of Oct. 1858, in relation to the condition of his knee-joint. He 
stated that on the 13th of August, 1858, while standing with the whole 
weight of his body resting upon the left leg, a mate struck him on the 
inside of the lower end of the left femur. The blow was made with the 
palm of the hand, but with sufficient force to throw bim down. It was 
immediately noticed that the tibia was partially dislocated inwards at 
the knee-joint. The whole lower part of the limb was inclined outwards. 
A person present in the room seized upon the foot and by extension 
easily brought it back to place ; the bone resuming its position w r ith an 
audible snap. After this he continued to w r alk about until night. Two 
days after, the knee had become so much inflamed that he was obliged 
to take to his bed, on which he was confined three weeks. Gradually 
the swelling subsided, and in about five weeks after the accident he be- 
gan to walk on crutches. On the 23d of Sept. he was walking in the 
store without crutches, when he suddenly felt a sensation of slipping in 
the joint, and he fell to the floor as if he had been tripped up. At the 
time when he called upon me, this had happened many times, but had 
never been attended with pain. The joint was filled w T ith synovia, and 
tender, yet I could distinctly feel a hard body just to the inside of the 
ligamentum patellae, and which moved freely under the finger. 

Prof. Le Fort 1 has described this accident as it occurred in his own 
person, in consequence of a forced flexion of the leg. He w 7 as conscious 
at the time of a movement in the joint at the external part of the right 
knee, and when he arose he found the limb fixed in the position of flexion, 
and he was only enabled to straighten it by a violent muscular effort, the 
effort being accompanied by a violent pain, and a very loud crack, as if 
something which was displaced had resumed its place. Immediately all 
pain disappeared and the motions of the joint were restored. For several 
months the accident was repeated whenever the knee was much flexed; 
the phenomena attending the displacement being in each case the same 
as ;it first, he having always a distinct recognition of the movement of 
displacement, and always the voluntary straightening of the limb repro- 
duced the crack, and caused the pain to cease. By avoiding the causes 
the accident ceased to occur; but after a time he failed to exercise the 
same caution, and the accident again occurred; but this time the dis- 

1 Le Fort, Bull. Soc. Chir., Paris, 1879, July 2. 



! 



INTERNAL DERANGEMENT OF THE KNEE-JOINT. 915 

placement of the cartilage was backwards instead of forwards, as it had 
been previously, and the straightening of the limb caused an atrocious 
pain, which lasted, in some degree, more than eight days. He has since 
then exercised the same caution as before and the displacement has not 
recurred. 

Pathological Anatomy, — The same class of symptoms, with only very 
slight modification, belongs probably to several varieties of k - internal 
derangement of the knee-joint V and first it will be remembered that the 
semilunar cartilages upon which the margins of the condyles of the femur 
rest, are attached to the tibia by several ligaments ; but when, from 
relaxation or a violent strain, any one of these ligaments becomes elon- 
gated or gives way. the portion of cartilage which it restrains is per- 
mitted to become partially displaced, and by interposing its thick margin 
between the deeper articulating surfaces the bones are separated and the 
muscles lose their control over the joint ; second, these ligaments may 
not only yield, but a fragment of one of the cartilages may become act- 
ually broken off from the main portion ; third, the femur may perhaps 
escape behind some portion of an interarticular cartilage, and thus, in- 
stead of the cartilage placing itself between the joint surfaces, the femur 
itself may have thrust it into this position ; fourth, a cartilage, or some 
portion of a cartilage, may become hypertrophied, and thus give rise to 
the symptoms described; fifth, in other cases still, a bony, cartilaginous, 
fibrinous, or calcareous growth or concretion forming within the joint, 
and, if originally attached, becoming separated from the capsule, may 
move about more or less freely, and give rise to the same class of symp- 
toms which I have described. 

This last variety has generally been described under the name of 
'•floating cartilages:'' but since these bodies are not always cartilagi- 
nous, and especially since they do not always by any means move so 
freely as to be properly designated as "floating," the term is less appro- 
priate than that originally given by Hey. and which I have chosen to 
adopt. 

Treatment. — For the purpose of obtaining immediate relief, it is gener- 
ally sufficient to flex the leg completely and then suddenly extend it. or 
to combine this motion with a slight twisting or rocking of the knee-joint. 
Sometimes this experiment has to be repeated several times before it i> 
completely successful, and in a few instances it lias failed altogether. I 
think I must have met with ten or twelve examples in the course of my 
practice, and in no instance has the sudden flexion and extension of the 
limb failed to overcome the difficulty. 

A- to the question of subsequent treatment, especially as to whether 
it is proper to attempt extirpation of the cartilages when they are found 
to be actually floating, or to make any other surgical interference, 1 
prefer to leave its consideration to those general treatises upon surgery 
where it more properly bel 



916 



DISLOCATIONS OF LOWER END OF THE TIBIA. 



CHAPTER XX. 

DISLOCATIONS OF THE LOWER END OF THE TIBIA 
(TIBIO-TARSAL). 

Syn. — "Dislocations of the ankle-joint; " Chelius and others. 

The tibia may be dislocated at its lower end in four directions; namely, 
inwards, outwards, forwards, and backwards. Most of these dislocations 
complicate themselves with fractures of the fibula or of the tibia, or with 
fractures of both bones. 

Dupuytren, Malgaigne, and a few other surgeons have reported ex- 
amples also of dislocations forwards and inwards. 

Boyer, with a majority of the French writers, and several English and 
German surgeons, speak of these dislocations as belonging to the foot ; 
consequently the outward dislocation of Boyer is the inward dislocation 
of Sir Astley Cooper, Malgaigne, myself, and others, who prefer to re- 
gard the tibia as the bone dislocated. 



Pig. 369. 



§ 1. Dislocations of the Lower End of the Tibia Inwards. 

Syn. — "Inward tihio-tarsal luxations;" Malgaigne. "Dislocations of the foot 
outwards ; " Boyer and others. 

Causes. — This dislocation is occasioned generally by a fall from a 
height, upon the bottom of the foot, the foot receiving at the same 
moment a sufficient inclination outwards to determine the main force of 
the impulse toward the inner side of the ankle. It may be produced 
also by a blow received directly upon the outside of the leg just above 
the ankle, or by a violent twist or wrench of the foot outwards. 

Pathological Anatomy. — I have already, in the chapter on fractures 
of the fibula, stated my opinion that a large majority of those accidents 

which have been called inward 
and outward dislocations of the 
tibia, were merely examples of 
lateral rotation of the astraga- 
lus within the half ginglymoid 
and half orbicular socket formed 
by the lower extremities of the 
tibia and fibula; and that true 
dislocations, either partial or 
complete, are at this joint and 
in these directions very rare 
occurrences. I shall continue, 
however, in accordance with the 
general practice of writers, to 
call them all dislocations, whe- 
ther the astragalus simply ro- 




bislocation of the lower end*of the tibia inwards 
/Toot turned outwardsj. (Pott's fracture.) 



DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 017 

tates on its axis, or is displaced laterally and horizontally from the 
tibia. 

In the most common form of the accident, then, when the foot is vio- 
lently twisted outwards, the astragalus heroines tilted ttpon its outer and 
upper margin in such a way that this margin slides inwards and places 
itself underneath the middle portion of the lower articulating surface of 
the tibia; its upper and inner margin descends toward the extremity of 
the malleolus internus. and the outer surface of the astragalus presents 
obliquely upwards and outwards, instead of directly outwards as it would 
do in its natural position. This cannot occur without a rupture of the 
internal tibio-tarsal ligaments, or a fracture of the malleolus internus. or 
both : indeed, a fracture of the internal malleolus is a very common cir- 
cumstance in connection with this form of dislocation. Much more fre- 
quently, however, the fibula itself gives way at a point within from two 
to five inches of its lower extremity; or sometimes the fracture in the 
fibula occurs through that portion which forms the malleolus extern us. 
For more particular information as to the causes and relative frequency of 
these fractures. I refer the reader to the chapter on fractures of the fibula. 

Rarely it happens that, instead of this lateral rotation of the astrag- 
alus, there occurs a true lateral displacement of the tibia inwards upon 
the astragalus, and the outer portion of the lower articulating surface 
of the tibia comes to rest upon the inner portion of the upper articu- 
lating surface of the astragalus: or it may slide completely off in the 
same direction: a result which is usually attended with a laceration of 
the muscles and integuments, converting the accident into a compound 
dislocation. In some cases this extreme displacement occurs without 
such laceration. 

In this form of the accident, the true lateral dislocation, the fibula may 
remain unbroken and undisturbed, the tibia merely having become dis- 
placed inwards; or the fibula may give way also above the articulation, 
while the malleolus internus, and the internal lateral ligaments, arc 
equally liable to rupture as in the other form of the accident. 

Sometimes, in addition to these complications, the lower end of the 
tibia is found to be broken obliquely upwards and outwards from the 
articulating surface, leaving that fragment attached to the fibula which 
corresponds to the inferior peroneo-tibial articulation. 

nptoms. — The foot is more or less violently abducted, the sole "I' 
the foot presenting downwards and outwards instead of directly down- 
wards; the malleolus internus projects strongly at the inner side of the 
joint: and at the outer side there is a corresponding depression, gener- 
ally most marked a little above the articulation near tie' point of frac- 
ture in the fibula. The pain is very L r re;it. and the fool is immovably 

fixed 80 far as the volition of the patient can determine motion, but the 

surgeon '-an generally move it pretty freely, yet not without causing a 
great increase of tic pain. When the dislocation is complete, and the 
fibula is also broken, the limb become- slightly shortened. 

Treatment. — When the accident i- of tic nature of ;< simple rotation 
of the astragalus upon it- axis, the reduction is often accomplished with 
the greal zing upon the fool and forcibly adducting 

Not unfrequently the patient himself, 



918 DISLOCATIONS OF LOWER END OF THE TIBIA. 

present, has effected the reduction before the surgeon is called. In 
other cases, and especially when it partakes of the nature of a true dis- 
location, much difficulty is sometimes experienced in the reduction. The 

Fig. 370. 




Dislocation of the lower end of the tibia inwards (foot turned outwards). 

surgeon ought then to flex the leg upon the thigh, in order to relax the 
gastrocnemii muscles, and holding the foot midway between flexion and 
extension, he should pull steadily upon it with his own hands, while an 
assistant makes counter-extension and supports the limb with his hands, 
grasping the thigh above the knee. At the same moment lateral pres- 
sure >liould be made upon the projecting bone in the direction of the 
articulation. It is of some use, also, occasionally to flex and extend the 
limb moderately, and to give to the foot a gentle rocking motion. If 
more force i> needed, it may be applied by placing the limb over a firm 
double-inclined fracture-splint, and making the extension by the aid of a 
screw attached to the foot-board, as I have suggested in certain cases 
of dislocation at the knee. Or we may employ the pulleys after the 
manner represented in the accompanying drawing, Fig. 371. 

Charles Sauer, aged about thirty years, while carrying a weight upon 
his shoulders, on the 6th of May, 1854, slipped upon the sidewalk, 
and fell, dislocating the left tibia inwards, and fracturing the fibula four 
inches from its lower end. I was in attendance soon after the accident 
occurred, and found the tibia projecting inwards, with the other symp- 
osually accompanying a simple rotation of the astragalus upon its 
axis. Seizing the foot with my hands and flexing the leg, while an 
nt held up the thigh and made counter-extension, I had scarcely 



DISLOCATIONS OF LOWER EXP OF TIBIA INWARDS. 919 

begun to pull upon the foot before the reduction was effected. Dupuy- 
tren's splint was at once applied, ami the subsequent inflammation was 

so trivial as scarcely to deserve notice. In six weeks the limb was 
sound, and free from all anchylosis. 

Fig. 371. 




In my report on dislocations, made to the New York State Medical 
Society for the year 1855, I have mentioned twelve similar examples, 
in addition to some examples of compound dislocations, all of which 
were easily reduced, but the results were not always so favorable. 

If. as rarely happens, the tibia is broken obliquely into the joint, 
the complete reduction of the dislocated tibia may be found impossible, 
owing to the obstacle presented by the displaced fragment. 

The following I am disposed to regard as examples of dislocation ac- 
companied with fracture of the tibia within the articulation : 

Brockway. of Cortland, N. Y., aged about twenty-seven years, con- 
sulted me. at my office, a few years since, in relation to the condition of 
his foot. I found the tibia dislocated inwards, and projecting more 
than an inch beyond the astragalus; the sole was turned outwards, 
compelling him to walk upon the inside of his foot : the fibula was bent 
inwards against the tibia, at a point about four inches above the ankle, 
which seemed to have been the seat of fracture of this bone. He stated 
to me, that immediately after the receipt of the injury, which was occa- 
sioned by a fall from a height upon the bottom of* his foot, he had con- 
sulted a surgeon, Dr. A. I>. Shipman, of Cortland, and thai although 
Dr. Shipman made repeated and violent efforts to effect the reduction, 
he had been unable to do so. Indeed, the bono had never been removed 
from the position in which it was at first placed. 

.1. Borland, of Erie Co., X. V.. aet. 31, fell under a rolling log, and 
dislocated his left tibia inwards, breaking off the internal malleolus, 
and fracturing the fibula four inches from it- lower end. Dr. Sweet- 
land, an old and experienced practitioner, was immediately called, who, 
with another surgeon, failed, after repeated efforts, to reduce the dislo- 
cation. I saw the- patient, in consultation with these gentlemen, twenty- 
four hours after the accident. The foot and ankle were somewhat 



!»^0 DISLOCATIONS OF LOWER E.ND OF THE TIBIA. 

swollen and discolored. The lower end of the tibia projected so far 
inwards as to threaten a rupture of the skin: the foot was strongly 
everted. We first flexed the leg upon the thigh, and made extension 
with our 1 lands, in the manner I have already directed. This we con- 
tinued several minutes: finally moving the limb in various directions, 
and adding forcible pressure upon the inside of the projecting tibia. 
We tli en placed the leg over a double-inclined plane, and, securing it 
firmly in place, we attached a screw to the foot through a sandal and 
gaiter, and while the leg was well flexed upon the thigh, we renewed 
the extension and lateral pressure. This was continued, with the appli- 
cation of more or less power, during half an hour, meanwhile changing 
the position of the limb occasionally by varying the angle of the splint. 
Our efforts were prolonged in all more than one hour, when, as Ave had 
made no impression upon the bone, and the patient had repeatedly im- 
plored us to desist, the attempt was given over. The end of the tibia 
seemed to rest partly upon the astragalus, and the extension was plainly 
all that was demanded, but the obstacle was beyond doubt within the 
articulation, or rather between the tibia and fibula. 

Four weeks after the accident, Mr. Borland walked on crutches, and 
during a year he was compelled to use a cane, but since that time a 
period of twelve years, he walked without any artificial support. For 
a year or two he felt a yielding in his ankle, as the weight of his body 
settled upon his limb ; but this gradually ceased, and for some years 
past he has walked without any halt, and seems to step as firmly as 
before the accident. . The foot still inclines outwards ; the tibia projects 
inwards one inch, and the broken ends of the fibula can be felt resting 
against the tibia, where they are reunited. 

Xot long since, I had occasion to amputate a limb for a compound 
di-loeation inwards, at the angle-joint, and the possibility of this frac- 
ture was confirmed by the dissection. About one-third of the outer 
portion of the articular surface was broken off obliquely, and the frag- 
ment was lying so displaced that a reduction would have been rendered 
impossible. 

Dr. Townsend, of Boston, has reported a case of compound dislo- 
cation, in which also amputation became necessary; and, with other 
injuries, the dissection show T ed a fragment from the outer margin of 
tin- tibia, one inch and a half long, and one inch thick at its widest 
part, with a very sharp point, displaced, and lying almost transversely 
over the astragalus. 1 

In 1842, A. Berard, 2 in order to effect reduction, divided subcutane- 
ouslv the tendo Achillis, and at the same time the peroneus longus and 
brevis. 

\ aim tin'' reports a case of dislocation forwards and imvards, which 
bad resisted all efforts. Tractions made by three strong assistants, while 
the patient was under the influence of chloroform, and at two different 
days, had produced no result. Valentin divided the tendo Achillis, and 
was then able to reduce the dislocation alone, and without the employ- 

:, Mass. H'>>p. Keports, Boston Med. and Surg. Journ., vol. xxxiii. p. 

L'77 

Berard, The Lancet, 1844, vol. i. p. 8. 
3 Valentin. These de Strasbourg, 1866, No. 970; Arch. Gen. de Med., t. 1, 1867. 



DISLOCATIONS OF LOWER END OF TIBIA OUTWARDS. 021 

ment of excessive strength. The patient recovered with a restoration of 
the natural motion of the foot. 

For a more full account of the prognosis and the general manage- 
ment of these cases subsequent to the reduction. I beg again to refer 
the reader to the chapter on fractures of the fibula: and for my views 
in relation to the treatment of compound dislocations of the ankle-joint. I 
will refer also to the chapter on compound dislocation of the long bones. 



>j 2. Dislocations of the Lower End of the Tibia Outwards. 

Sv)t. — ''Outward tibio-tarsal dislocation ;" Malgaigne. "Dislocations of the foot 
inwards. ;! of others. 

The causes are the same or similar to those which are known gen- 
erally to produce dislocations inwards : only that the force of the con- 
cussion or the direction of the rotation must have been reversed. 

The external lateral ligaments, peroneo-tarsal, are either ruptured, 
or the lower portion of the fibula gives way, or both of these cir- 
cumstances may have happened ; 

while the internal malleolus may Fig. 372. 

also yield to the shock and to 
the weight of the body now rest- 
ing upon it. The nature of the 
accident may vary also in respect 
to the relative position of the ar- 
ticular surfaces ; the astragalus 
may simply rotate on its inner 
and upper margin, or the tibia. 
with the fibula, of course, may 
actually slide outwards until the 
lower end of the tibia more or 
less completely abandons the 
upper surface of the astragalus. 

Treatment. — The modes of re- 
duction, and the general princi- 
ples of treatment, will not differ 
from those which I have men- 
tioned as suitable for dislocations 
in the opposite direction. The 
examples which have fallen under 
my observation are not numer- 
ous, but the reduction has always 
been easily effected. Tim-. ;i 
man, ;»-t. 21, fell from n scaffold- 
ing, alighting upon hi- feet. He 
that his left foot struck the 
ground obliquely, and upon it< 
outer margin. I found the fibula 
projecting very strongly out- 
ward-, evidently carrying with 

it the tibia: the malleolus internus was broken off', and the foot forcibly 
turned inward-. Without either flexing the leg upon the thigh or call- 




Difloc&tiou of the lower end of the til 

war I 



922 DISLOCATIONS OF LOWER END OF THE TIBIA. 

ing to my aid any degree of counter-extension except what was made by 
the weight of the body, I grasped the foot and drew upon it gently, 
while at the same moment I rotated the foot outwards. Immediately the 
bones resumed their places. 

In June of 1840, Henry Wilson, ret. 38, consulted me in relation to 
his foot, which he said had been dislocated four weeks before. He had 
fallen upon the outside of his foot and turned it suddenly inwards, so 
that when he looked at it he found the sole presenting toward the oppo- 
site side. Seizing upon it with both hands, he pressed it forcibly out- 
wards, and the reduction immediately took place with a snap. Very 
little soreness followed, nor was he confined to his house a single day. 
Be had continued to walk about with only a slight halt in his gait, nor 
would he have thought it necessary to consult me at all except that the 
tenderness had not yet disappeared. He was not aware that the fibula 
had been broken also, until I called his attention to the fact. The frac- 
ture had taken place two inches above the ankle; and although it was 
already united, the depression occasioned by its having fallen in some- 
what toward the tibia was very plainly felt and recognized. 

§ 3. Dislocations of the Lower End of the Tibia Forwards. 

Syn. — "Forward tibio-tarsal luxations;" Malgaigne. "Dislocations of the foot 
1 Kick wards," of others. 

Causes. — This dislocation may be produced by a violent extension of 
the foot upon the leg; as, for example, when, the foot being engaged 
under a piece of timber, the body falls backwards to the ground; or it 
may be caused by a fall upon the bottom of the foot, the foot resting upon 
a Blightly inclined plane. It may be caused also by any of that class of 
accidents which are known to produce fractures of the fibula with fracture 
of the malleolus internus, or fracture of the fibula with rupture of the 
internal lateral ligament; for example, by a fall upon the bottom of the 
foot, or upon the inside of the sole, followed immediately by an outward 
twist of the foot. In these cases the dislocation of the foot backwards, or r 
as it is generally found to be, the semiluxation, maybe consecutive upon 
the accident, and the result only of contraction of the gastrocnemii. It 
may, therefore, occur immediately after the fracture has taken place, or 
not until afterthe lapse of several days. 

Pathological Anatomy. — The displacement may be very slight, so 
that the end of the tibia is only a little advanced upon the astragalus; 
or it may be such that the tibia rests one-half upon the naviculare and 
""♦'-half upon the astragalus, or it may even desert the astragalus en- 
tirely. The fibula may at the same time be broken at any point, but it 
i- generally broken two or three inches above its lower extremity. The 
malleolus internus is also sometimes broken, but more often the 'internal 
lateral ligament is torn. Still more rarely a fracture occurs through the 
ior mar-in of the articular surface of the tibia. 

Symptoms. — The length of the foot in front of the tibia is diminished, 

while the projection of the hod is correspondingly increased ; the toes 

turned downwards and the heel drawn upwards, and fixed in this 

position : the end of the tibia may generally be distinctly felt in front of 



DISLOCATIONS OF LOWER END OF TIBIA FORWARDS. 



923 



the astragalus: the extensor tendons of the toes are sharply defined, 
while the tendo Achillis is curved forwards, and tense. 

At the regular meeting of the New York Pathological Society, No- 
vember 2'2. I860. I presented a specimen obtained from the dissecting- 
room of the Bellevue Hospital College. The history of the ease was 
unknown. 

Before dissection, the foot was observed to be turned outwards, and 
shortened in front of the tibia, while there was a corresponding length- 
ening of the heel. The specimen, after dissection, disclosed a fracture 
of the internal malleolus half an inch above its lower end, and a fracture 
of the fibula a little above its lower end. The tibia was displaced for- 
wards about three-quarters of an inch, so that only the posterior half of 
its lower end rested upon the articular surface of the astragalus, and at 
the point of contact with the astragalus a new socket was formed in the 
tibia, concave upwards, half an inch deep, and presenting an appearance 
as if the posterior lip of the lower end of the tibia had been broken off 
and had become displaced upwards. It was supported by a broad but- 
tress of bone. It is not certain, however, but that this appearance was 



Fig. 



Fig. 374. 






Partial dislocation of the tibia forwards, 
with fractures of malleolus internus, and 
fibula. Skeleton. 



Partial dislocation of the tibia forwards, 
with fracture of the malleolus internus, and 
fibula. 



sioned solely by the long-continued pressure of tin- tibia upon the 
astragalus ;it this point. The fragments of the malleolus internus, and 
the lower fragment of tin- fibula, remained attached to their upper frag- 
ments and to the two sides of the astragalus in their normal positions, 
quently each fragment was inclined downwards and backwards al 
an angle of*4.7'. The lower fragmenl of the fibula was driven upwards, 
also, but both of the fractures were firmly united. This specimen is no* 
in the museum of* the Bellevue Hospital Coll< 

A- the same meeting of the Pathological Society I reported the 1 
of Mary Conlan, aet. 38, admitted to Bellevue Hospital, November 13, 
1865, having been thrown three days before from ;< Btreet-car. She 
could give no account of the manner in which she fell. 1 saw her 
16th. The limb was then much swollen, and I diagnosticated 
a fracture of the lower end of the fibula. (It bad ben supposed to be 



924 DISLOCATIONS OF LOWER END OF THE TIBIA. 

a mere sprain up to this time.) The limb was directed to be wet with 
cool water, and to rest upon a pillow. From this time I looked at it 
occasionally, to see whether the swelling had sufficiently subsided to 
warrant the application of a splint. November 20th it was examined 
again carefully by the house surgeon, Dr. Farrall, but no displacement 
was noticed. November 23d I found the lower end of the tibia dis- 
placed forwards, and ascertained, also, that the internal malleolus was 
broken at its base. The dorsum of the foot, measuring from the front of 
the tibia to the end of the great toe, was shortened half an inch. The 
heel was lengthened. 

There can be no doubt that in this case the dislocation occurred sub- 
sequent to the fracture, and that it was caused by the contraction of 
tlie gastrocnemii. I reduced the dislocation a day or two later, and 
maintained it in position by the method which I shall presently describe. 

Dr. Voss reported to the Society a similar case which had come 
under his notice, and Dr. Buck remarked that he also had met with 
such examples. 1 

In May, 1878, I found in my wards at Bellevue an old subluxation of 
tli is character in the person of Catharine Brady, aet. 30; the cause of 
which I was unable to ascertain precisely. 

Dr. Prince, of Illinois, has reported a case of this character, which, 
remaining displaced, led to a prosecution for damages. A lady, set. 
4<>. met with an accident, August 31, 1863, which resulted in a fracture 
of the fibula near its lower end, and a partial dislocation of the tibia 
forwards to the extent of one inch. The toes were not pointed down- 
wards, but the foot had its natural angle with the leg. Nearly three 
months after the accident, Dr. Prince, assisted by two other surgeons, 
broke up the adhesions, and reduced the bones to their natural positions. 2 

Treatment. — The reduction is to be attempted by flexing the leg upon 
the thigh, and making extension from the foot, while, at the same mo- 
ment, pressure is made upon the front of the tibia and against the heel. 
Winn the bone begins to slide into place, the foot should be forcibly 
flexed upon the leg. A slight lateral motion or rotation in either direc- 
tion may assist in restoring the bones to place. 

In general, the dislocation has been easily reduced, but in a majority 
of the examples recorded, great difficulty has been experienced in main- 
taining the reduction ; and in a few cases it has been found impossible to 

do 80. 

In order to maintain the reduction, the leg, flexed upon the thigh, 
may be laid on its back in a box; and the foot supported firmly against 
a foot-piece placed at a right angle with the box. In this position the 
\\<-i L r]it of the leg will tend somewhat to overcome the action of the mus- 
cles, which are disposed to displace the foot backwards. Generally it 
will he found necessary to make additional pressure directly upon the 
front <>f the lei: above the ankle: which, in order that it may not prove 
mischievous, musl bo effected with some soft material, and must be ap- 

1 New Y..rk Journ. Med . April, 1866, p. 40. 

ncinnati Journ. Med., April, 1867, p. 202. See also Todd's Cyclopedia of 
Anat. and Phys.; Adams on Ankle-joint, p. 160 et seq. 



DISLOCATIONS OF LOWER END OF TIBIA FORWARDS. 925 

plied over a broad surface. Perhaps nothing will better answer these 

indications than to pass a cotton hand, six or eight inches in width, 
through slits or mortises in the sides of the box : these slits being of a 
width equal to the width of the band, and placed at a point sufficiently 
below the level of the spine of the tibia, so that when the band i- made 
fast underneath the box. it shall press the leg firmly backwards. To 
prevent the heel from suffering in consequence of this pressure, it also 
should be supported, or suspended by another band passing underneath 
the heel and fastened above to the top of the foot-board. 

The plaster-of-Paris dressing, also, answers the purpose exceedingly 
well in these cases ; indeed, as I have explained more fully in connection 
with the subject of Pott's fracture, I must regard it as the most effective 
means for preventing these accidents, as sequences of this fracture : and 
as the most certain means for retaining the bones in position when, the 
displacement having actually occurred, they are again put in place. 

Dupuytren relates the following example of this accident : 

Pierre Froment. aet. 33, was carrying a heavy weight upon his back 
and had his right foot in advance, when by accident he came suddenly 
in contact with a beam placed across his path. Under the fear of being 
precipitated forwards, he made a sudden effort to throw his body back- 
wards, by which he lost his balance, and fell with the point of the left 
foot inclined inwards and forwards, and his whole w r eight was thrown 
first on the outer side, and then on the front of the ankle-joint. 

On examination, the leg seemed to be planted upon the middle of the 
foot : the toes were directed downwards and the heel drawn up. On 
the instep there was a large bony prominence, over which the extensor 
tendons of the toes were stretched like tense cords. Behind the joint 
was a deep hollow, at the bottom of which the tendo Achillis could be 
felt forming a tense, resisting, semicircular cord, with its concavity 
directed backwards. The fibula was also broken; the lower end of tin- 
lower fragment remaining attached to the foot, while the upper end of 
the <ame fragment was carried forwards by the displacement of the tibia, 
so that it lay nearly horizontally, with its broken extremity directed 
forward.-. 

Dupuytren directed one assistant to fix the leg, and a second to make 
extension from the foot, while Dupuytren himself, standing on the outer 
side of the limb, forced the heel forwards and the tibia backwards. The 
first attempt succeeded partially, and the second completed the reduction. 
The limb was then placed in the apparatus employed by tin- surgeon for 
a fractured fibula, which I have before described, and laid on Its outer 
side in a semiflexed position. The patienl recovered rapidly, and in 
little more than a month ho was able to walk. 1 

But such fortunate results have not usually been observed; indeed, 
Dupuytren encountered much more serious difficulties in two other cases 
which came under his own ootice, one of which ho ha- himself recorded. 
This was in the person of a woman ;"t. 48, who was brought to 1" Motel 
Dieu in 1815, the accident having just happened from a -lip in going 
down stair.-. The fibula was broken, and also a fragment waa broken 

1 Dupuytren, Injuries and I>i-. ol B Ion <•<!.. p. 2 



926 



DISLOCATIONS OF LOWER END OF THE TIBIA. 



from the tibia. The house surgeon reduced the hones, and placed the 
limb in the ordinary apparatus for broken legs ; but on the following day 
Dupuvtren found them redislocated, and laid the limb on his own splint, 
but the pressure requisite to keep the tibia in place soon induced slough- 
ing, ulceration, and abscesses, and after four months' treatment, during 
which time the tibia had been repeatedly' displaced, she left the hospital, 
able to use her limb, but with a certain amount of incurable deformity. 1 

Malgaigne mentions the third example as having been seen by himself 
in Dupuytren's service in 1832, in which case the attempt to maintain 
the reduction by a tourniquet resulted in gangrene and finally the death 
of the patient. 2 Earle lost a patient after amputation made on the eighth 
day. The tibia could not be kept in place, and the amputation became 
necessary on account of the final protrusion of the bone through the 
integuments, which had sloughed. 3 

Reginald Harrison, 4 who had seen three cases of this dislocation, prac- 
tised section of the tenclo Achillis for the purpose of maintaining the 
tibia in place, and with complete success. 

^ 4. Dislocations of the Lower End of the Tibia Backwards. 

Syn. — " Backward tibio-tarsal dislocation ;" Malgaigne. " Dislocations of the foot 
forwards." of others. 

More rare than the dislocations forwards, Malgaigne has, nevertheless, 
succeeded in collecting five examples. 

They appear to have been produced, generally, by a cause the reverse 
of that which we have seen to produce in certain cases the preceding 



Fig. 37 



Fig. 





Dislocations of the lower end of the tibia backwards. 

dislocation. Thus, while the dislocation forwards is produced sometimes 
when the foot is in violent extension, this dislocation has occurred, in at 
Least two or three cases, when the foot was forcibly flexed upon the leg. 



Dupuytren, op. cit. 
Malgaigne, op. cit., 



p. 270. 
p. 1044. 



2 Malgaigne, op. cit., p. 1044. 

* Harrison, The Lancet, 1876, vol. i. p. 



DISLOCATIONS OF UPPER END OF FIBULA FORWABDS. 927 

The svmptoms are strongly marked and characteristic. The length of 
the foot from the tibia to the ends of the toes is increased one inch or 
more, the heel being correspondingly shortened, or rather wholly obliter- 
ated : a portion of the articulating surface of the astragalus may be dis- 
tinctly felt in front of the tibia : the posterior surface of the tibia touches 
the tendo Achillis : the leg is shortened, and the malleoli approach the 
sole of the foot. 

In most cases one or both of the malleoli have been broken ; and R. 
W. Smith, who has reported one of the examples alluded to, believes 
that the dislocation is never complete. 

Bv letter I am informed that a similar case came under the observa- 
tion of Dr. S. B. Ward, of Albany, N. Y., in November, 1882. The 
patient had fallen from a scaffold, and Dr. Ward found him with a frac- 
ture of the internal malleolus and a dislocation of the tibia backwards, 
the signs of which were characteristic and marked. Reduction was easily 
effected, and was accompanied with an audible snap. There was no 
apparent tendency to a recurrence of the dislocation, and there resulted 
finally a complete restoration of the motions of the ankle-joint. Dr. 
Ward remarks incidentally, that he has found another case reported by 
M. Poland, in Guy's Hospital Reports for 1855. 

Reduction should be attempted by a method similar to that which has 
been recommended in all the other dislocations of the ankle, only with 
such modification as the peculiarities of the case must necessarily suggest. 



CHAPTER XXI. 

DISLOCATIONS OF THE UPPER END OF THE FIBULA. 

— ; ' Dislocations of the superior peroneo-tibial articulation ;" Malgaigne. 

SURGEONS have frequently described a condition of the peroneo-tibial 
articulation in which the ligaments have become relaxed, giving ;i preter- 
natural mobility to the head of the bone. It is also Dot anfrequently 
displaced upwards, in consequence of an oblique fracture of the tibia. 
I have myself seen several examples of both these accidents : but simple 
traumatic dislocations, which can only occur forwards or backwards, are 
very rare (Boyer 1 relates a case in which both the upper and lower pero- 
neal extremities were dislocated, and the foot dislocated outwards). 

§ 1. Dislocations of the Upper End of the Fibula Forwards. 

Malgaigne has collected three examples of* this dislocation, observed by 
Savournin, Jobard, and Thompson, respectively, uncomplicated with any 

other accident: and not. apparently, due to any abnormal condition of 
the ligaments; two of which, at least, seemed to have boon produced by 

1 Boyer, Trait, defl Mai Chir.. t. 1. p. 



DISLOCATIONS OF UPPER END OF THE FIBULA. 

the violent action of the muscles which, arising from the anterior face of 
the fibula, traverse below the anterior surface of the foot. The third 
example, reported by Thompson, permits a doubt as to whether the dis- 
placemenl was occasioned by muscular action, or by a direct blow upon 
the part. 1 

The Bigns which characterize the anterior dislocation are the absence 
of the head of the fibula from its natural position, and its presence in 
front, near the ligamentum patellae ; the altered direction of the biceps 
flexor cruris muscle; and, in one case, considerable deformity in the 
shape and position of the leg has been observed. 

Thompson and Jobard 2 were unable to accomplish the reduction while 
the leg was extended upon the thigh, but succeeded readily after having 
flexed the leg. In Thompson's case the bones returned with a distinct 
crepitus. Savournin's case is related by Goyrand 3 from memory. A 
woman, set. 35, in falling caught her right foot, turning it violently in- 
wards. Savournin was called at once. He flexed the leg violently, in 
order " to relax the muscles going from the anterior face of the fibula to 
the dorsal surface of the foot," and then easily pushed the bone into its 
place with his fingers. The patient was kept in bed eight days, no 
dressings or splints being applied, and on the twelfth day she was dis- 
missed cured. Malgaigne thinks that flexion of the leg, combined with 
flexion of the foot, would render the reduction more easy. 

In whatever position the limb is placed, the surgeon must rely chiefly 
upon forcible pressure made with the fingers against the front and upper 
portion of the displaced bone. 

J. E. Hawley, of Ithaca, N. Y., late Professor of Surgery in the 
Geneva Medical College, has furnished me with a brief account of a case 
which came under his observation : 

On the 29th of March, 1854, Bambak, while vaulting upon the paral- 
lel bars in a gymnasium, unintentionally made a complete somersault, 
and fell with his right foot upon the edge of a plank. Dr. Hawley, who 
was immediately called, found his right leg semiflexed and immovably 
fixed. The head of the fibula was plainly felt in front of its natural 
position, near the ligamentum patellae. The patient was suffering the 
most intense pain. Extension and counter-extension were made, and 
while the doctor was pressing with both of his thumbs upon the head of 
the fibula, it went into its place with an audible snap. The relief was 
instantaneous. Complete rest was observed for a few days, while cooling 
lotions were constantly applied, and within a week he was able to attend 
to hi< usual duties. 

§ 2. Dislocations of the Upper End of the Fibula Backwards. 

Sanson has recorded one example, in which the passage of the wheel 
of a carriage across the upper part of the leg, precisely on a level with 
the peroneotibial articulation, ruptured the ligaments which bind the- 
fibula to the tibia, and caused a displacement, which, however, seems to 

'• Thompson, The Lancet, 1850, vol. i. p. 385. 
- Jobard, Rev. Med. Chir., 1853, t. 14, p. 114. 
Savournin, Goyrand. Clin. Chir., Paris. 1870, p. 111. 



DISLOCATIONS OF UPPER END OF FIBULA BACKWARDS. 929 

have been spontaneously overcome. Nevertheless, there remained a pre- 
ternatural mobility, permitting the fibula to be pushed easily backwards 
or forwards upon the tibia. 1 

Sanson did not think that a permanent dislocation could be produced 
at this joint, but that the bone would be restored to its socket inevitably 
by the strong resistance offered by the aponeurosis attached to the head 
of the fibula: and Malgaigne seems not to have considered the case 
related by Sanson as a fair example of complete backward dislocation. 
It is my opinion however that, considering the nature and direction of 
the force applied, and the character of the symptoms present, it ought to 
be regarded as a complete backward dislocation: in which, however, the 
aponeurosis not being much disturbed, the bone was easily restored to its 
position and retained. 

The first unequivocal case of this dislocation, unaccompanied by other 
complications is related by Dubreuil. 2 

A man. aet. 32, in order to save himself from filling, sprang sud- 
denly, with his right leg in a position of extreme abduction, and at the 
same moment he experienced a severe pain in the region of the peroneo- 
» tibial articulation. The head of the fibula was found to be thrown back- 
wards, and formed under the skin a marked prominence: the foot was 
drawn outwards, and the whole outside of the limb became cold and 
numb. Dubreuil flexed the leg moderately, and pressing the head of 
the fibula from behind forwards, the reduction was easily effected. On 
the following day. the limb having been straightened, the dislocation was 
found to be reproduced. It was again replaced, and the knee covered 
with a leather cap. secured moderately tight. After twelve days of com- 
plete rest, the knee was moved gently, and on the seventeenth day the 
patient walked with the help of a cane. For some time the leg had a 
tendency to incline outwards ; but in about three months the cure \\;i- 
perfectly established. 

It is probable that in this latter case the dislocation resulted from the 
violent action of the biceps flexor cruris. Such, at least, is the opinion 
of both Dubreuil and Malgaigne. and I see no reason to question the 
correctness of their theory. 

Erichsen mentions that a gentleman, 23 year- old. fell in descending 
the Alps, with his leg bent forcibly under him. dislocating the head of 
the fibula backwards. When -eon by Mr. Erichsen it was found impos- 
sible to reduce it. owing to the tension of the biceps. !!<■ suffered no 
pennanent inconvenience from the accident, except that this limb was a 
little weaker than the other, and he could not jump. 1 

Another example has been reported by Dr. Jos. ( >. Richardson, resi- 
dent physician to the Pennsylvania Hospital. John Dixon, ;<-t. '••. fell 
five feet 'and struck upon the outside of the left knee. When admitted 
to the hospital, the leg was partially flexed and tie- to,- ;) little everted, 
and he was unable to flex or to extend tli<- limb completely. The head 
of the fibula was seen three-quarters of an in<-li behind its natural posi- 

1 Sanson, Diet de Med. -t Chir matt] u 

2 Dubreuil. Journ. de Chir., 1844, \>. 214, from A 

3 Erichsen. Science and Art of Surgery, A ;■■ MO 



980 DISLOCATIONS OF LOWER END OF THE FIBULA. 

tion. ami the biceps was felt distinctly attached. There was no other 
lesion. The reduction was easily accomplished by pressing with the 
fingers upon the inner and back part of the fibula, thrusting it outwards 
and forwards. A compress and bandage were applied, and the limb 
placed at rest. The reduction continued complete, and after a few days 
ho was permitted to use the limb. 1 

I find in the St. Louis Medical and Surgical Journal for March, 
L881, copied from the Canada Journal of Medical Science, the case of 
a boy ;et. '2 years, who had fallen from a chair, and on examination 
t\\.» weeks later, the doctor found the head of the fibula displaced back- 
wards. It was easily replaced, and without pain; but some months later 
the Burgeons in attendance were unable to retain it in place. 

Bryant says he has seen three examples of the backward dislocation, 
hut gives no account of them. 2 



CHAPTER XXII. 

DISLOCATIONS OF THE LOWEK END OF THE FIBULA. 

— " Luxations of the inferior peroneo-tibial articulation;" Malgaigne. 

Kxcepting Boyer's case of dislocation of both the upper and lower 
end- of the fibula, already referred to, Nelaton relates the only example 
of a simple dislocation of this articulation of which I have any infor- 
mation. The patient who was the subject of this accident presented 
himself at the hospital under the care of M. Gerdy on the thirty-ninth 
day after the accident, which had been occasioned by the passage of the 
wheel of a carriage obliquely across the leg in such a manner as to push 
the malleolus externus directly backwards. The lower end of the fibula 
was in almosl direct contact with the outer margin of the tendo Achillis; 
the outer face of the astragalus, abandoned by the fibula, could be dis- 
tinctly felt in nearly its whole extent; the foot preserved its natural 
position ; and he could walk pretty well, only that he was obliged to step 
with -nme care. M. Gerdy believed that the bone was too firmly fixed 
in it- new position to be moved, and therefore made no attempt at re- 
duction. 

! Richardson, Amer Journ. Med. Sci., April, 1863. 

Practice of Surgery, Eng. ed. of 1872, p. 810. 



DISLOCATIONS OF THE ASTRAGALI'S. 



931 



CHAPTER XXIII. 



TARSAL DISLOCATIONS. 

§ 1. Dislocations of the Astragalus. 

Svn. — " Double dislocations of the astragalus ; " Malgaigne. 

The astragalus may be dislocated forwards, outwards, inwards, back- 
wards ; or it may be dislocated obliquely in either of the diagonals be- 
tween these lines ; it may be simply rotated upon its lateral axis, without 
much, if any, lateral displacement; and, finally, it has been occasion- 
ally driven between the 

tibia and fibula, tearing FlG - 3 "7- 

away the intermediate 
ligaments, and generally 
fracturing one or both 
bones of the leg. 

Causes. — The causes 
which have been found 
chiefly operative in the 
production of this disloca- 
tion are very much the 
same as those which pro- 
duce, under other circum- 
stances, a dislocation of 
the lower end of the tibia. 
Thus, a fall from a height upon the bottom of the foot, accompanied 
with a violent abduction, adduction, flexion, or extension, may determine 
a dislocation of the astragalus inwards, outwards, backwards, or forwards. 
Sometimes it is accomplished by a mere wrenching and twisting of the 
foot in machinery, or in the wheel of a carriage, or by being caught 
between two irregular bodies. It may be produced also by a direct blow. 

Symptoms. — The great prominence occasioned by the displacement 
of the bone in either of these Beveral directions, accompanied generally 
with more or less lateral deviation of the foot, is alone sufficient to 
indicate the true nature of the accident. In some cases, also, the foot is 
forcibly flexed or extended : the leg is shortened in consequence of the 
tibia having fallen down upon the calcaneum ; the superincumbent skin 
and tendon- are rendered tense; blood is effused, and swelling Bpeedjly 
occurs. In the backward dislocation, the position of the foot La Dot much 
changed, but the tibia being slightly carried forwards, the length of the 
dorsal aspect of the f'<»"t i- proportionately diminished. 

To be more precise, I shall quote ;it Length from the careful analysis of 
this subject made by Poinsot in the French edition of this treatisei 




Dislocation of the astragalus outwards, 
relations. 



TARSAL DISLOCATIONS. 

"The Bigns of the different varieties of dislocation of the astragalus 
may he briefly stated as follows : 

•• The dislocation forwards^ which is very rare, is characterized by the 
prominence of the astragalus on the dorsal surface of the foot, at a point 
corresponding exactly to the space midway between the two malleoli, or 
to the dorsal Burface of the scaphoid bone; that prominence is movable 
upon the foot and upon the bones of the leg. 

•• In the dislocation forwards and outwards, the most common of all, 
the f«»nt is in a state of strong adduction, its extremity being directed 
inwards, and its internal border being shortened and concave. The tibia 
rests upon the calcaneum, instead of the astragalus, and seems as if em- 
bedded in the soft parts ; the fibula gives rise to a marked projection on 
the outside. Through the stretched integuments, in front and on the 
outside, the articular facetta of the astragalus can be recognized. 

•• When the dislocation has been produced forwards and inivards, the 
projecting astragalus is felt at that point; moreover, the foot is slightly 
abducted, with its external border elevated; but the characteristic sign 
consists in the change of direction taken by the astragalus, whose head 
i- directed downwards, its axis having thus become parallel with that of 
the tibia. 

•• The dislocation directly backwards is characterized by the projection 
of the astragalus between the tibia and the tendo Achillis, which is 
pushed backwards; in addition to this displacement backwards, the as- 
tragalus undergoes a rotation in the direction of its transverse axis, which 
brings its superior surface forwards and the inferior one backwards. The 
tibia being slightly carried forwards, the dorsal surface of the foot is 
shortened. 

•• In the dislocations backwards and inwards, or backwards and out- 
wards, the projecting astragalus is felt behind the corresponding 
malleolus. 

"The symptoms observed following a dislocation inwards are: forced 
abduction of the foot; the existence, below the malleolus externus, of an 
enormous depression, into which the integuments maybe pushed; the 
very marked projection of the internal malleolus, below which the facetta 
of the astragalus is felt directed completely inwards. 

•• The gigns are reversed in the dislocation outwards, viz. : forced ab- 
duction of the foot ; projection of the malleolus externus, below which is 
the facetta of the astragalus turned outwards; depression below the 
malleolus internus. 

" I be clinical history of the dislocations by rotation or by renverse- 
ment is too incomplete vet to give any hope of their diagnosis being 
lished with precision. I will relate, however, in the way of infor- 
mation, what has been written by M. Delorme regarding the signs 
which, according to his statement, would enable one to diagnosticate the 
dislocations of the astragalus by renversement or upside down. 

•■ If. in the dislocation without rotation, the two bony borders of the 

pulley of the astragalus be looked for, they begin to be felt very near the 

at 1 or 1\ centimetres from it. In the dislocations by rotation (of 

egreee or by renversement), on the contrary, the projections by 

which the inferior and posterior articular surface of the astragalus is 



DISLOCATIONS O F T H E A STRAGALUS. 



033 



limited, and which were taken for the margins of the facet, are 3| to 4 
centimetres behind the head, two fingers' breadth, as Chassaignac has ob- 
served, who did not take advantage of this sign to establish liis diagnosis. 

•• In dislocations without rotation, the interval separating the two bony 
margins of the facet of the astragalus is 3 centimetres, measured directly 
over the bone. It would exceed 8 centimetres, but would not reach 4. 
on a foot covered by the soft parts and swollen. In dislocations by rota- 
tion, the interval separating the projections which overhang the posterior 
articular surface of the astragalus is already 4 centimetres. The thick- 
ness of the soft parts and the swelling would increase it to nearly 5 centi- 
metres. 

•■ Finally, by careful search, it would not be more difficult to feel the 
depression of the articular surface, between the two projecting eminences 
of the inferior surface of the astragalus, than to feel the flat part of the 
superior surface, which is commonly recognized in the double dislocations 



Fig. 378. 



Fig. 379. 





Simple dislocation of the astragalus 
outwards. 



Compound dislocation of 1 1 
inwanls. 



without rotation. At any rate, establishing the absence of tin- surface 
would be the acquisition of a valuable sign. 

Such are the Bymptoms which may ordinarily enable as to recognize 
the true character of these displacements when not much swelling e 
even though the -kin is not broken and tli<- bones are not exposed ; but 
in a majority of the examples which have been Been, the integuments 
have been more or less extensively torn, exposing to the eye at once the 
naked bone, and thus removing all chance of error in the diagn 

Norris mentions a case seen by Qammersley, in which the astragalus 
was thrown completely out. and was subsequently found in the earth 



934 TARSAL DISLOCATIONS. 

where the patient had received his injury. Inflammation, gangrene, and 
tetanus supervened, and the patient died on the seventh day. 1 

Prognosis. — It will be readily understood that nothing short of very 
great violence could disturb and completely break up the connections of 
8 bone so compactly and firmly seated as is the astragalus, and that, 
aside of any unusual complications, under the most favorable circum- 
Btances, intense inflammation must naturally be anticipated; and, with 
few exceptions, this has actually taken place. Even when reduction 
has been promptly and easily effected, inflammation, gangrene, and death 
have Bometimea speedily ensued. But more often the reduction has been 
Pound to be exceedingly difficult or impossible, and complete removal of 
the hone or amputation has been immediately demanded. 

In a limited number of cases, on the other hand, the bone has been 
easily reduced, and recovery has taken place, with a tolerably useful 
limb: or resection has been practised with an equally favorable result; 
in -till other cases the bone has been left protruding, and the patient 
has finally recovered so far as to be able to walk again, but in such a 
crippled condition as to render the achievement a very doubtful triumph 
of conservative surgery. 

M. Poinsot has attempted to decide, by means of figures, in what pro- 
portions these very opposite results are to be hoped for or feared. 

''Out of seventy-eight cases of simple double dislocation collected by 
M. Broca, he finds that nineteen were reduced. M. Dubrueil; since the 
date of publication of Broca's statistics, counted five reductions out of 
twelve cases of double dislocation without any primary wound. Begin- 
ning in 1864, when Dubrueil's statistics were published, I have been 
able to collect thirty-one cases of simple double dislocation, in which 
attempts at reduction were made, and which furnished nineteen suc- 
3. Twenty-one of the latter cases were published elsewhere : in 
that number, reduction had been effected twelve times ; of the nine other 
patients, one had suffered immediate amputation, and the last eight had 
been submitted, at least at the beginning, to the expectant treatment." 

According to Broca, the attempt at reduction failed in 54 cases out 
of 63. 

Poinsot narrates briefly other cases collected by himself, and which 
have been reported by Gueniot, 2 Busch, 3 Iverson, 4 Gore, 5 Uthoff, 6 Ward, 7 
Fairbank, 8 Hird, 9 Landerer, 10 Lloyd, 11 and F. H. Hamilton. 12 

"Out <>f the eleven preceding cases, therefore," says Poinsot, "reduc- 
tion was successful eight times; in the other three cases, extirpation of 

1 Norris, George W. Amer. Journ. Med. Sci., 1837, p. 383. 

'-' Gueniot, (.a/, des Hop., 1872, No. 94. 

• Busch (Madelung), Berliner Klin. Wochen., 1873, 7 u. 8. 

4 Ivereon, Nordiskl Med. Ark., 1876, Bd. 8, Hft. 3. 

. Til- Lancet, 1880, vol. i. p. 625 

■ CTthoff The Lancet, 1880, vol. i. p. 701. 

7 Ward, The Lancet, 1880, vol. i. 

8 Fairbank, The Lancet, 1880, vol. i. p. 745 
1 II ird, The Lancet, 1878, vol. i. p. 311. 

"' Landerer, Central, fur Chir., 1881, p. 609. 

11 Lloyd, The Lancet, 1882, vol. ii. p. 353. 

11 Hamilton, 5th od. of this treatise, 1880, p. 774. 



DISLOCATIONS OF THE ASTRAGALUS. 985 

the astragalus had to be performed at a varying period following the 
accident. The three patients operated upon recovered in -rood condition. 

"By adding our statistics to those of Broca and o\' M. Dubrneil, we 
reach a total of 121 cases of reduction with 43 successes, making an 
average of successes of 35.5 per cent. I will call attention to the fact 
that our personal statistics, which are more recent than the two other-. 
furnish an average of successes not below 61.2 per cent. 

'*In the fortunate cases, three times (cases of Orosse, Bryant, Moore), 
the reduction could not be accomplished until after the tendo Achillis had 
been divided; such was the case with Cock's patient, mentioned by 
Dubrueil. In two of the cases where reduction could not he effected, 
the surgeons (Busk, Cheevers) had not only divided the tendo Achillis. 
but also the tibialis posticus, the extensors of the toes, and the extensor 
proprius pollicis. Pichorel, of Havre, was not more successful, but he 
had only divided the tendo Achillis. Broca has reported four additional 
cases of tenotomy, taken from Chaussier, Despaulx. Solly, and from the 
clinic at Marseilles: reduction was only obtained twice. I will also state 
Shaw's case, recalled by Dubrueil, and in which the division of the 
tendon of the flexor longus did not effect the reduction. After all, 
tenotomy, practised in twelve cases, effected the reduction six times, thus 
giving an average of 50 per cent., which exceeds by 15.6 per cent, that 
furnished where attempts at simple reduction w T ere made. With such 
results, one may be allowed to wonder why tenotomy is not resorted to 
more frequently in cases of irreducible dislocations. 

" It is especially in the dislocations backwards that failures at reduc- 
tion have been most frequent: in twenty cases which we have been able 
to collect, reduction was effected only four times. The first one of those 
eases was reported by Malgaigne, without any author's name: the only 
indication as to its origin states that it was observed in 1839, in one of 
the hospitals of London; the displacement, which had occurred inwards 
and backwards, was reduced in ten minutes, by means of strong exten- 
sion combined with lateral pressure. Erichsen, although insi^tim: upon 
the extreme difficulties that are met with in the dislocations backwards, 
declares that the Burgeons of the University Hospital of London recently 
succeeded in a case which was complicated with a fracture of both bones 
of the leg. Erichsen advises the subcutaneous section of the tendo 
Achillis in cases where the ordinary procedures have failed. The third 
case was published in detail by Dr. Blatin, of Clermont-Ferrand: \ 
man 50 years of age, robust and muscular, falling into ,-i cellar Prom 
a height of several feet, dislocated the astragalus directly backwards: 
the displacement was incomplete as to it- relations with the articular 
ends of the tibia and fibula, complete a- to its relations with the scaphoid 
and both articulations of the ealeaneum. ML Blatin, in order to obtain 
the reduction, resorted to the following procedure: 

••• I made vigorous traction upon the ealeaneum, in order to diseng 
that bono from the groove of the astragalus and so as to obtain sufficient 
room for the return of the astragalus. Then 1 extended the fool strongly 
upon the leg, in such manner as to disengage the hollow al the articula- 
tion of the ealeaneum with the astragalus, and so as to use the posterior 
and superior portion of the ealeaneum as a means of pushing tie- astrag- 



936 TARSAL DISLOCATIONS. 



alu 



forwards. . . . After the second attempt, the astragalus had 
resumed its normal position.' Finally, in 1875, Dr. Morgan stated, at 
the Pathological Society of London, that he had recently seen a case of 
dislocation of the astragalus backwards, without fracture, where the 
reduction was easily effected. 

,k In eight cases out of fifteen, the results of which are known to us, 
failure ar reduction did not deprive the limb of more or less usefulness. 
Lizars states thai he saw a case of dislocation backwards where, although 
all attempts at reduction had failed, the limb was saved, and afterwards, 
the patient could use it pretty well. Such was the result in a case in 
Mr. Liston's practice. Phillips has published two cases of dislocation 
backwards which had resisted all efforts : the two patients walked easily, 
notwithstanding the persisting displacement; one of them wore a shoe 
cut behind in order to avoid pressure upon the projecting astragalus. A 
patient of Cheevers, to whom I have already alluded when speaking of 
tendinous sections, recovered notwithstanding the gangrene of the skin 
on a level with the astragalus ; five months after, he walked pretty easily 
with a cane. In the two other cases, the dislocation had not been recog- 
nized in the beginning, and had been mistaken for a fracture ; one of 
them has been reported by the author of this treatise. 

"Dr. MacCormac, in 1875, presented to the Pathological Society of 
Loudon a specimen of dislocation of the astragalus taken from a subject 
who had had the leg amputated for a chronic affection of the knee. The 
dislocation dated back two years, and had been treated for a fracture. 
Tho deformity was very slightly marked, and the patient walked easily 
with the aid of a cane. He could climb a ladder and walk on the scaf- 
foldings. At the dissection, the head of the astragalus was found in 
place, but the body of the bone was displaced backwards and adhered to 
the tendo Achillis; the other tendons passed on the sides of the dislo- 
cated portion of the bone. At the same meeting, Dr. MacCormac re- 
called a similar fact of Mr. Legros Clark, which dated back to 1863: 
the patient when seen again recently (1875), twelve years after, walked 
very well with his unreduced dislocation. 

11 But, in a certain number of cases, the expectant treatment resulted 

in gangrene of the skin over the projecting astragalus, and extraction of 

the bone had to be resorted to. Such was the measure adopted in two 

by Foucher, Buchanan, and Williams, of Dublin. In each case 

the operation was followed by success. 

" In a patient of M. Pichorel, of Havre, two attempts at reduction 
and Bection of the tendo Achillis were followed by a purulent arthritis 
which required amputation. 

•• Immediate extraction of the astragalus, in dislocations backwards, 
mIv been practised twice, by Hulme, of Dunedin, and by Turner; 
the latter case being a compound dislocation. In both cases, the results 
of the operation were sufficiently satisfactory. 

•• Tho expectant plan of treatment which has been relatively fortunate 
m dislocations backwards, has only been followed by deplorable results 
in other displacements of the astragalus. Out of seventeen cases, I count 
only two successes; and out of the fifteen failures, there was one death 
by gangrene, nine consecutive extractions, and one amputation. 






DISLOCATIONS OF THE ASTRAGALUS. 937 

••The two successes belong to Dupuytren and Dr. Barton, of Phila- 
delphia. I take from M. Dubrueil the very brief history of the first 
one of these eases: ' In a simple and complete dislocation outwards, ob- 
served by Dupuytren, the bone could not be replaced : there occurred a 

superficial eschar which did not communicate with the articulation, and, 
two months after the accident, the patient could use the limb very well.' 
Barton's case, and the one preceding, present the greatest similarity; 
the inflammation was severe, and the sphacelus exposed the projecting 
portion of bone ; but after the lapse of a certain time the skin cicatrized. 
Five months later, the patient could walk and use the articulation well, 
although a well-marked deformity of the foot still existed, and notwith- 
standing the fact that every now and then new ulcerations of the cica- 
tricial tissue would occur. 

••In a second case of Barton, however, extensive gangrene occurred. 
soon after the accident, and the patient died. 

"In a patient of Dauve, suffering with a dislocation of the astragalus 
forwards and outwards, with rotation on its antero-posterior axis, the 
pressure upon the integuments produced gangrene, and the exposed as- 
tragalus became necrosed. The result is not known to us, but the case 
may already be considered as one of the failures by the expectant plan. 
Two patients of Guthrie, in whom a similar displacement could not be 
reduced, could not possibly use their feet. A soldier, seen by Sir Wm. 
Fergusson, and who had a dislocation of the astragalus dating several 
years back, could only walk with the aid of a cane, and applied only the 
tip of the foot to the ground. 

"Dr. Wilson, of Manchester, has reported a case of dislocation out- 
wards of two years' standing. The right foot turned strongly inwards. 
it rested on the ground with its external border, the point d'appui being 
represented by the external borders of the calcaneum and of the fifth 
metatarsal bone. The patient could not age the foot. There existed at 
the external side of the dorsal aspect a voluminous projection ; the integ- 
uments, at that point, would get inflamed on the slightest fatigue, and 
had ulcerated on several occasions. Wilson amputated the leg, and the 
patient recovered. 

' ; The cases of secondary extraction have given one death, winch oc- 
curred in the practice of Dr. Smith, of Leeds. A tall and robust e< n- 
tleman dislocated the astragalus while jumping out ofa carriage, on May 
14. 1*<;4. The .kin sloughed, the hone became loose, and Mr. Smith 
extirpated it on the 14th of June. One month after, the patient died 
with eschars on the sacrum. The same surgeon scores three recoveries 
out of three operations which he performed, the patients being able to 
use their limbs perfectly. An equally good result waa obtained in the 
cases of Busk, Cruveilhier, Lallemand, Loewer, and Shillitoe. 

"The dangers of the expectant method [except perhaps in the hack- 
ward dislocation — EL]and the almost absolute necessity of resorting sob 
sequently to extraction of the astragalus, have suggested to a certain 
number of surgeons the immediate performance of that operation. Such 
was the procedure which 1 adopter) j,, ;i case mentioned above, in the 
chapter on Fractures of the Astragalus ; I will recall the fact that the 
patient died after having undergone amputation of the thigh : the extir- 



TARSAL DISLOCATIONS. 

patioo was incomplete, as I had left in place the head of the bone which 
had maintained its relations with the scaphoid." 1 

George W. Nbrris, of Philadelphia, relates the following case, illustrating 
the imminent danger to which even the life of the patient maybe exposed 
in those examples which are apparently the most simple: 

William Summerill, aet. 30, was admitted to the Pennsylvania Hospi- 
tal on the 26th of September, 1831. An hour previous, while descend- 
in-- a ladder, lie slipped and fell in such a manner as to throw the entire 
weight of his body upon the outer part of his left foot. The foot was 
turned inwards, and nearly immovable; a slight depression existed im- 
mediately below the lower end of the tibia, and there was a hard rounded 
projection on the outer part of the foot, a little below and in front of 
the extremity of the fibula; the skin over this projection was not broken 
or excoriated, but reddened; there was no fracture of either bone of 
the leg. 

The symptoms rendered it plain that the astragalus was dislocated 
forwards and outwards. Dr. Barton, under whose care the patient was 
received, proceeded soon after to make attempts at reduction. The 
muscles of the leg were relaxed as much as possible, and extension 
made from the foot by seizing the heel and front part of the foot while 
an assistant made counter-extension at the knee. The bone was also 
pushed inwards toward the joint by the surgeon. These efforts were 
continued for a considerable time, but had no effect in changing the 
position of the bone. 

Six hours afterwards, Drs. Harris and Hewson being in consultation, 
the attempt was again made to accomplish the reduction, but without 
success ; and the surgeons immediately proceeded to excise the bone. 

An incision was made parallel with the tendons, commencing a short 
distance above the projection, and extending down far enough to expose 
fairly the astragalus and its torn ligaments. The bone was then seized 
with the forceps and easily removed after the division of a few liga- 
mentous fibres that continued to connect it with the adjoining parts. 
\ civ little bleeding occurred, only two small arteries requiring the 
ligature. 

After removal, it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and that 
it remained firmly attached to the extremity of that bone. No attempt 
was made to remove this fragment; but, the joint being carefully sponged 
out, the Bides of the wound were brought together and closed by sutures, 
adhesive >t)a]»s. and a roller; after which the foot, placed in its natural 
position, was laid in a fracture-box. 

On the fifth day a slough began to form upon the outside of the foot, 
which was followed by suppuration at other points, and on the thirteenth 
day an opening was made to evacuate the pus near the malleolus in- 
terims. At the end of about eight weeks the fragment of the astragalus 
which had been suffered to remain was found to be carious, and it was 
removed; the heel also had ulcerated from pressure, and several other 
bones of the tarsus were discovered to be carious. Fifteen months later, 

insot, French ed. of this treatise, p. 1182 et seq. 



DISLOCATIONS OF THE ASTRAGALUS. 939 

this poor fellow was still in the hospital. Buffering from hectic, with ex- 
tensive disease in the bones of the tarsus and ankle-joint. Finally, 
amputation of the leg was practised by Dr. Barton, a few days after 
which the patient died. 1 

Norris mentions also two examples of simple dislocation of the as- 
tragalus at the Pennsylvania Hospital which came under the observation 
of Dr. Barton, in both of which the bone was left unreduced. In one 
case inflammation and sloughing soon effected a complete exposure of 
the protruding bone, but after a time the skin cicatrized. At the end 
of five months the patient walked and had good use of the joint, though 
great deformity of the foot existed, and he continued to be subject to 
ulceration of the newly formed skin on its outer part. In the other case 
gangrene supervened soon after the accident, and the patient died. 

Norris adds that k, the late Professor Wistar removed the astragalus 
in a case of compound dislocation, and the patient was cured with some 
motion at the joint." 

Dr. Alexander Stevens, of New York, made the same operation in 
a case of compound dislocation, and, after several months, he affirms that 
the patient "has recovered with very trifling deformity of the foot, and 
with a flexible joint. He walks with very slight lameness." 2 

I am indebted to Dr. B. H. Hart, of Marietta, Ohio, for an account 
of the following case, and for the specimen, which has, also, kindly been 
put in my possession. 

In June, 1853, Thomas Williams was thrown from his carriage, 
alighting upon his left foot and causing a compound dislocation of the 
ankle-joint. Dr. Hart was immediately called, and found the bones of 
the leg thrust through the integuments on the outside, the malleolus 
interims broken, and the astragalus partially dislocated. After enlarg- 
ing the opening in the integuments with a pocket-knife, the doctor was 
able to reduce the dislocated bones. It must be mentioned that this 
man weighed 225 pounds, and that in his fall he descended a precipice 
or bank 30 feet in height. Soon after the reduction the patient had two 
severe convulsions, which were arrested by bleeding and opiates, and 
never returned. Cool lotions were applied to the limb : and on the 
sixth day erysipelas supervened and extended nearly to the body. The 
erysipelas continued about nine days. Extensive suppuration throughout 
the joint resulted, and some fragment- of the bone came away, and on the 
thirty-third day Dr. Hart removed, without the aid of the knife, the 
entire astragalus. In three months the patient walked upon crutches, 
and in eleven months he could walk well without a staff, a Blighl motion 
having been preserved in the ankle-joint. 

The dislocations backwards, of which we have found recorded only 
twenty example-, have all, with but four exception-, been left unre- 
duced; yet in Beveral instances the patients have recovered with pretty 
useful limbs. Such was the fact with Liston's, Lizars, and my own 
patients, and also with Mr. Phillips's two cases, to all of which I shall 
again refer. It must be noticed, however, that, in each of the cases 

i Noi W. t Amer. Journ. M - \ ig 1887, | 

2 Stevens, North Amer. Med. and 8urg. Journ., Jan l s -!7. p 200. 



940 TARSAL DISLOCATIONS. 

mentioned as followed by a successful termination without reduction, the 
dislocations were simple. 

Turner, of Manchester, lias reported one example of compound dislo- 
cation outwards and backwards, in which, finding himself unable to effect 
reduction, he removed the astragalus, with a tolerably successful result. 1 
Finally, a case was presented in one of the London hospitals in 1839, of 
a dislocation inwards and backwards, which was reduced in about ten 
minutes, by extension accompanied with lateral pressure. 2 

In Sept. 1870, I saw, with Dr. Say re, in consultation, a subluxation 
of the astragalus forwards and outwards, in the person of Mr. Stewart, 
of this city, which had just occurred in consequence of an injury re- 
ceived in being thrown from a carriage. The dislocation seemed to be 
nearly but not quite complete, causing great projection and tension of 
the skin. Under the influence of chloroform, by extension and pressure, 
it was easily reduced by Dr. Sayre. In five weeks from this time he 
was able to walk, and soon after the restoration of the functions of the 
joint was complete. 

Basil Norris, Surgeon U. S. A., in a paper read before the American 
Surgical Association in 1883, reports a case of dislocation of the astraga- 
lus forwards and outwards, caused by being thrown from a carriage, and 
alighting upon his foot. In less than an hour after the accident, under 
the influence of ether, it was reduced by Drs. Lincoln and Ashford, of 
Washington. The method employed was to draw the foot forcibly down- 
wards, while it was at the same time rotated outwards. The first 
attempt was unsuccessful; but in the second, the extension being aided 
by direct pressure, the bone was at first partially restored to its position; 
the restoration being finally completed by continued extension, and by 
direct pressure upon the neck of the astragalus. No grave inflammatory 
accident ensued. The same paper contains communications from several 
Burgeons reporting similar cases ; only one of which, that of Dr. John 
Brinton, of Philadelphia, 3 had been previously reported. 

In Dr. Brinton's case, the astragalus was dislocated forwards and 
inwards, and the fibula was broken, but the integuments were not torn. 
Several ineffectual attempts at reduction were made on the same day by 
Drs. Brinton and Moss. A severe inflammation ensued, with other 
alarming symptoms, and on the 14th day Dr. Brinton practised excision. 
A portion of the os calcis subsequently became carious, and was removed, 
and he finally recovered with a tolerably useful limb. 

A communication from Dr. J. W. S. Gouley, contained in the same 
paper, gives an account of a case of simple dislocation forwards and out- 
ward- which he had reduced. Reference is made also to other cases 
seen by Drs. Gouley, Vollum, and Agnew, but not with sufficient pre- 
cision to render their repetition in this place useful. 

Treatment. — Various attempts have been made by surgical writers to 
determine the line of treatment which should be adopted in these un- 

1 Turner, Trana Provra. Med. and Surg. Journ., vol. ix. Essay on Dislocations of 
aralus, with nearly fifty cases. For additional cases, see Med. and Surer. Keporter, 
Jan. 1867. 

London Lancet, vrol. ii. p. 559. 

Photographic Rev., No. 2, Dec. 1870. 



DISLOCATIONS OF THE ASTRAGALUS. 941 

fortunate cases, but with very unsatisfactory results, since they are far 

from having arrived at similar conclusions, nor have they beeD able 
always to settle the question definitely for themselves. The difficulty 
consists in the multiplicity and lack o\' uniformity in the complications 
which attend these accidents, rendering it impossible to establish a clas- 
sification upon which a uniform treatment may be safely based There 
are certain principles, however, which seem to be sufficiently settled to 
allow of an authoritative announcement : these may be briefly stated as 
follows: If the dislocation is simple, reduce the astragalus immediately, 
provided this is possible. If the dislocation is complete, and it cannot be 
reduced, even partially, except in cases of dislocation backwards, proceed 
at once to resection or to amputation. In compound dislocations, resec- 
tion or amputation affords the only safe resource. In all cases the in- 
flammation is likely to be intense, in order to prevent which complication 
the surgeon must be unremitting in his use of the appropriate remedies. 

The several indications and rules of treatment above enumerated I 
shall proceed to illustrate a little more fully. 

In a recent simple dislocation of the astragalus forwards, the leg should 
be flexed to a right angle with the thigh, and, for the purpose of making 
extension, one assistant should take hold of the foot in both hands in 
the same manner that a servant draws a boot, that is, with the righl 
hand grasping the heel, and the left placed upon the dorsum of the foot. 
near the toes. A second assistant should seize the lower pari of the 
thigh, in order to make counter-extension, while the surgeon presses with 
the ball of his hand against the head of the astragalus, upwards and 
backwards. If these simple measures fail, the pulleys ought to he 
employed as a substitute for the hands it) making extension. In applying 
the extension, the toes must be kept well down, and occasionally the foot 
should be moved gently from one side to the other. 

An oblique dislocation must be reduced, if possible, to an anterior 
dislocation, before an attempt is made to carry the head of the bom- back 
to its place, as by this mode the reduction will be greatly facilitated. 

Lateral dislocations maybe reduced by the same means; hut if tin- 
astragalus is dislocated outwards, the foot must he held forcibly adducted 
during the extension; and if it is dislocated inwards, the foot must he 
held strongly in the opposite direction. 

Lizars says that lie ha- seen one case of backward dislocation, and that 
all attempts at reduction were unavailing. The limb was, however, 
preserved, and proved to be useful. 1 Listen was equally unsuccessful in 
a case which came under his notice.- Phillips ha- reported two cases, in 
neither of which was the reduction accomplished. 1 Nelaton has seen a 
compound dislocation which he could nol reduce.' Mr. Erichsen, how- 
ever, who believed that when dislocated backwards it had not hitherto been 
reduced, declares that the surgeons at University Hospital have succeeded 
in one case recently, in which both the tibia and fibula wen- broken 

1 Lizar-. System of Practical Surg . Edinburgh ed., 1 S 17. p. 161. 

2 Listen, Elements of Surgery, vol iii. p 

3 Phillips, Lond. Med. Gaz . vol. xiv. p. 

4 Nelaton, Pathologic Chirurg.,t. ii. p 182 

5 e, limer. -I 1-' 



942 TARSAL DISLOCATIONS. 

Mr. Grichson suggests also that, in case of a failure by the ordinary 
means, we should resort to a subcutaneous section of the tendo Achillis. 
Mr. Williams, of Dublin, in a similar case, which had been left unre- 
duced, was obliged finally to extract the bone, in consequence of the 
integuments having sloughed. 1 

In February, 1875, Mr. J. N. Hall, of Colorado, set. 38, consulted 
me in reference to an injury to his foot sustained two years before. The 
foot had been caught between a couple of timbers and violently twisted 
inwards. The nature of the accident was not at first recognized. I 
found the astragalus displaced backwards as far as the posterior extremity 
of the ealeaneum, causing the tendo Achillis to curve backwards; the 
astragalus was especially prominent on the inner side, posteriorly. The 
foot was at a right angle with the leg, and shortened in front three-eighths 
<»t' an inch. The leg was shortened five -eighths of an inch. The foot was 
at times painful and numb. He walked very well with the aid of a cane. 
Of course, no surgical interference could be recommended. 

Compound dislocations, and such as are otherwise complicated, demand 
of the surgeon immediate amputation or exsection, the latter of which 
ought to be preferred whenever the condition of the limb encourages a 
reasonable hope that the foot may be saved. 

Dr. Grant, of Canada, has reported a case of success after reduction 
of a compound dislocation of this bone. The man was 35 years old, 
and in good health. Immediately after the accident the astragalus was 
found completely dislocated forwards, and lying with its long axis placed 
transversely, so that the anterior extremity protruded through the integu- 
ments one inch on the outer side of the foot. There was no fracture. 
The first attempt at reduction, by extension and pressure, failed ; but in 
the second attempt moderate pressure, without extension, was successful. 
Suppuration ensued, and continued two months. At the end of eight 
months he walked without a cane ; and at the date of the report the 
ankle was in all respects perfect. 2 

•• In the dislocation by rotation, or renversement," says M. E. Delorme, 
"if the bone has been rotated upon its antero-posterior axis to the extent 
of 90 degrees, thus having brought its trochlear surface inwards or out- 
wards, it is necessary, in order to effect reduction, that while pulling on 
the foot, the bone should be tilted, outwards in inward dislocation, and 
inwards in the external variety, which is done by pressing upon the 
margin of the facet which has become superior. In a case of dislocation 
by renversement, the surgeon must try first, by a tilting motion, to con- 
vert thai rotation of 180 degrees into one of 90 ; and then to press again 
upon one of the margins of the bone, in order to transform the displace- 
ment into an ordinary dislocation inwards or outwards." 

When exsection is practised, and the bone is found to be broken, as it 
often is, all the fragments should be carefully removed, since they are 
certain to become necrosed if left in place. "This happened," Poinsot 
remarks, " in the cases of Barton and Smith, and the accidents which 
occurred in Sampson's patient and in mine, seem to me to be due to the 

1 Williams, Krichsen, op. cit., p. 271. 

at, Canada .Mod. Journ., Oct. 1865. 



ASTRAGALO-CALCAXEO-SCAPHOID DISLOCATIONS. 943 

fact that the extirpation had been incomplete.** Nor ought the surgeon 
to hesitate to lay open freely the tissues in every direction, in order that 
he may accomplish this purpose: even the tendons lying over the pro- 
truding bone may be sacrificed unhesitatingly, since, after having been 
so severely bruised, stretched, and lacerated, they are pretty certain to 
slough. Indeed, the more freely the tissues are divided over the bone, 
the less will be the danger of inflammation, and the safer wiU he the life 
and limb of the patient. 

In addition to the examples already cited of compound dislocation in 
which the astragalus was removed, the following, reported by Dr. W. A. 
Gillespie, of Ellisville, Va., will also illustrate the occasional value of 
exsection in these severe accidents. 

Mrs. A., aged about 50 years, fell from a horse on the 23d of Maw 
1833, dislocating both ankles. The dislocation of the right foot was ac- 
companied with a dislocation of the astragalus outwards, which projected 
through a very large wound in the integuments, and its trochlea, was 
placed at an angle of about 45° with its natural position. Early on the 
following day it was removed by severing its few remaining connections, 
and the wound was immediately closed by stitches, adhesive plasters, and 
light dressings. From the moment of the receipt of the injury, and for 
several days afterwards, she suffered excruciating pain in the limb, and 
on the third day tetanus was apprehended, but its full accession was pre- 
vented by the free use of opiates. The limb was suspended in N. R. 
Smith's fracture-apparatus ; and as gangrene with hectic fever soon 
threatened the life of the patient, fermenting poultices were diligently 
applied, and the patient was sustained by wine, bark, and other tonics. 
Two months after the injury was received, the date at which the report 
is given, the wound had entirely healed, and her complete recovery was 
regarded as certain. 1 

§ 2. Astragalo-Calcaneo-Scaphoid Dislocations. 

It is perhaps quite as common for the astragalus to be dislocated from 
the scaphoid bone and calcaneum, while it retains its connections with 
the tibia, as to be dislocated from all these bones at the same time. This 
astragalo-calcaneo-seaphioid dislocation is that which Malgaigne has 
termed " subastragaloid." Produced by the same causes which deter- 
mine true dislocations of the astragalus, it may occur in the Bame direc- 
tions, and is liable to the same complications; nor will either the prog- 
nosis or treatment differ essentially from that which is recognized and 
established in the other accident. 

As in dislocations proper of the astragalus, so also in this accident, 
opposite resulte have occasionally followed from similar modes of treat- 
ment. Thus, Dr. Detmold, of New York, stated in L856 to the New 
York Academy of Medicine, that lie had recently met with a dislocation 
of the astragalus, in which the bone had retained its proper relations with 
the tibia, but not with the bones of tic tarsus. The patient had fallen 
from a wagon and caught his foot in the wheel. Dr. Detmold made 

1 Gillespie, Amer. Journ. Med. - 562. 



**44 TARSAL DISLOCATIONS. 

extension with pulleys, but could not effect the reduction. Subsequently 
he was obliged to remove the astragalus on account of the suppuration 
which followed and the consequent exposure of the bone. The wound 
did not heal kindly, and at length amputation of the leg became neces- 
sary. 

Dr. Detmold concludes, from this example and others which have 
come to his knowledge, that if a similar case were to present itself to 
him again, he would amputate at once. 1 

The following case reported by Dr. Thomas Wells, of Columbia, S. C, 
is of unusual interest, as illustrating the danger of leaving the bone dis- 
placed, and also the benefit which may, even under the most unfavorable 
circumstances, result from its final removal: 

Dr. S., set. 30, was riding in an open carriage, some time during the 
vcar 1819, when his horses became frightened and ran, and in leaping 
from his vehicle he struck upon his left foot, dislocating the astragalus 
from its junction with the scaphoid bone, upwards and slightly outwards. 
Several medical gentlemen made violent efforts to reduce the bone, but 
without effect. Inflammation and suppuration, accompanied by a high 
fever, soon followed, and the head of the astragalus, becoming carious, 
protruded through the skin. On the 18th of August, about seven months 
after the injury was received, he was still suffering from a copious dis- 
charge, pain, swelling, and general irritative fever, and it was deter- 
mined to excise the bone ; which was accordingly done by enlarging 
the wound and detaching its loose connections with the adjacent tissues. 
The astragalus extracted left a frightful wound, the foot seeming to be 
nearly separated from the leg. A hollow splint was adjusted to the 
inside of the foot and leg, so as to preserve the limb perfectly steady and 
in a proper direction; simple dressings were applied, and an anodyne 
administered internally. No accidents followed, and at the end of Sep- 
tember the wound was healed, and the swelling of the parts had entirely 
subsided. One year after the operation, he walked without the least 
difficulty; the ankle being then perfectly sound. The leg was shortened 
a hoi it one inch, and this deficiency was supplied by a thick heel upon 
his shoe. 2 

Examples might be cited illustrative of the value of early exsection 
where reduction could not be accomplished; but, after what has already 
been said upon the subject of dislocations of the astragalus, I shall not 
regard any farther reference as either necessary or useful. If other 
principles of treatment are to govern the surgeon than those which I 
have already laid down, they cannot here be stated. They are among 
those unwritten rules whose existence we cannot always recognize until 
the case ari.-es to which they may apply. Yet, in the exigency sup- 
posed, they are as clearly defined, and as imperative, in the mind of the 
clever surgeon, as any of those laws which have been made the subjects 
of special record. 

1 Detmold, New York Journ. Med., May, 1856, p. 383. 

2 Wells, Aiikt. Journ. Med. Sci., May, 1832, p. 21. 



DISLOCATIONS OF THE CALCANEUM. 945 



§ 3, Dislocations of the Calcaneum. 

The calcaneum may, as a consequence of a fall upon the heel, or of 
a direct blow, be dislocated outwards from the astragalus alone, or up- 
wards and outwards from the cuboid bone at the same time. It has 
been found also, according to Canton, at the same moment dislocated 
outwards from the astragalus and inwards upon the cuboid bone. 

Chelius says he has seen an old dislocation of the calcaneum, pro- 
duced in early life by pulling off a boot, from which there finally resulted 
a degeneration like elephantiasis of the leg, rendering amputation neces- 
sary. 1 

Mr. South remarks, in his notes to Chelius, that the two cases of 
dislocation outwards of this bone, mentioned by Sir Astley Cooper, 
were from his (South's) Notes (cases 199 and 200). In the first case, 
that of Martin Bentley, occasioned by the falling of a heavy stone upon 
his foot, the integuments were not broken, and the position of the foot 
resembled a varus. " The dislocation was easily reduced, having bent 
the thigh and knee on the body and fixed the leg, by laying hold of the 
metatarsus and of the tuberosity of the heel-bone, and drawing the foot 
gently and directly from the leg, during which extension Cline put his 
knee against the outside of the joint, and the foot being pressed against 
it, the heel and the navicular bone readily slipped into their place, and 
the deformity disappeared." He was discharged from the hospital in 
five weeks, "having the complete use of his foot." . 

In the second case, the dislocation, produced also by the fall of a stone 
upon the foot, was compound, and the patient, Thomas Gilmore, having 
been brought into St. Thomas's Hospital, the reduction was effected by 
extending the foot and rotating it outwards. Six months after, when he 
left the hospital, he was able to walk pretty well with a stick. 

A. Dumas 2 relates an example of this dislocation outwards, caused by 
a piece of wood falling upon the internal side of the leg and foot. Jourdan, 
of Marseilles, in whose service the case was presented, reduced it easily 
by extension downwards and outwards,. combined with direct pressure. 

In another case reported by Dumas, a man had been struck upon the 
posterior and external part of the heel, and imprisoned by an anchor; in 
which condition of the limb, the body was thrown to the left. Jourdan 
reduced the dislocation easily, as in the preceding ease. At the end of 
a month the cure was complete. 

Dr. Edwin Canton 3 found in the dissecting-room of the Charing-Crosa 
Hospital, what he regarded as a traumatic dislocation outwards upon the 
astragalus and inwards upon \\\c cuboid. Malgaigne and Poinsol bave 
accepted Canton's view of the ease, but Polaillon could interpret it only 
as a pathological displacement. 

Hancock* describes a specimen taken from an old man who bad re 
ceived his injury two years before death, causing a dislocation outwards, 

1 Chelius, - 

« .\. Dumas, Bull. Therap., 1864, t. 46, ; 

" E. Canton, Ti 

216. 

60 



<>4»l TARSAL DISLOCATIONS. 

which had not been reduced. Dissection showed that the calcaneum was 
slightlv separated from the cuboid, and more extensively from the astrag- 
alus, whose position in the articulation was completely changed. The 
astragalus, tibia, fibula, and calcaneum were anchylosed by bony callus. 

§ 4. Middle Tarsal Dislocations. 

The scaphoid and cuboid bones may be dislocated from the astragalus 
and calcaneum, constituting what is termed, by Malgaigne, a "middle 
tarsal " dislocation. It is probable that, to some extent, the same thing 
has occurred in many of those cases which are reported as simple disloca- 
tions of the astragalus, or as dislocations at the astragalo-scaphoid articu- 
lation : but it occurs also occasionally in a degree so perfect and complete 
as to leave no doubt as to the true nature of the disjunction, and to 
entitle it to a separate consideration. 

Mr. Liston mentions the case of a boy, set. 14, who fell from a height 
of forty feet, striking, apparently, upon the extremity of the foot. The 
scaphoid and cuboid bones were found displaced upwards and forwards, 
bo that the foot was shortened about half an inch, and had a clubbed 
appearance. No attempt was made to reduce the bones, and he left the 
hospital in three weeks, able to stand on the foot. 1 

Sir Astley Cooper has recorded in more detail a similar example. A 
man, working at the Southwark bridge, London, received upon the top 
of his foot a stone of great weight. He was immediately carried to 
Guy's Hospital, and his condition is described as follows : " The os calcis 
and the astragalus remained in their natural situations, but the forepart 
of the foot was turned inwards upon the bones. When examined by 
the students, the appearance was so precisely like that of a club-foot, 
that they could not at first believe but that it was a natural defect of 
that kind ;" but, upon the assurance of the man that previous to the acci- 
dent his foot was not distorted, extension was made, and the reduction 
was effected. He was discharged from the hospital in five weeks, having 
the complete use of his foot. 2 

E. Delorme 3 mentions two cases observed by Thomas and Anger, re- 
spectively. 

In Thomas's case, the foot had been traversed by the wheel of a wagon. 
Reduction could not be effected, and the patient died. The autopsy dis- 
closed a displacement upwards of the astragalus and calcaneum upon the 
second row of the tarsal bones. The scaphoid was broken, and one of 
its fragments protruded at the sole of the foot. The cuboid was only 
partially dislocated from the calcaneum. 

In Anger's case, a man had fallen from a height, and the arch of the 
fool appeared a little flattened, but the displacement of the bones could 
not be made out. The patient having died of erysipelas, the autopsy 
revealed a complete dislocation of the astragalus and calcaneum forwards 
upon the Becond row of the tarsal bones. The tubercle at the anterior 

ical Surgery; also London Lancet, vol. xxxvii. p. 133. 
2 Sir A. Cooper od Disloc., etc., London ed., 1823, p. 376. 
■ Delorme, Thomas, and Anger. Poinsot, op. cit., p. 1210. 



DISLOCATIONS OF THE SCAPHOID BONE. 947 

portion of the scaphoid was almost entirely torn away. Even after dis- 
section it was found difficult to reduce the bones. 

§ 5. Dislocations of the Cuboid Bone. 

According to Piedagnel, quoted by Chelius, the cuboid bone may be 
dislocated upwards, inwards, and downwards, but Malgaigne affirms that 

he has found no case recorded in which the dislocation has occurred 
alone, or unaccompanied with a dislocation of one or more of the other 
tarsal bones. 

§ 6. Dislocations of the Scaphoid Bone. 

Burnett has seen a dislocation of the scaphoid bone in which its con- 
nections with the astragalus were undisturbed, while at the same time it 
was completely separated from the cuneiform bones. By strong pressure 
exercised during several minutes, the os scaphoides was made to fall into 
its place. The dislocation was compound, yet the wound healed rapidly, 
and in a short time the recovery was almost complete. 1 

Rizzoli 2 also reports an example of simultaneous dislocation of the as- 
tragalus and scaphoid in a direction "inwards, upwards, and forwards," 
the injury being caused by jumping from a carriage. Rizzoli succeeded 
in effecting reduction with the aid of three assistants, by making counter- 
extension from the knee, the leg being in a position of semiflexion, while 
direct pressure was made upon the projecting scaphoid; Rizzoli himself 
seized the toes and the heel with his two hands, and made traction, 
bringing at the same moment the foot upwards. 

Garland, 3 of Liverpool, saw a child ret. 4, with a compound dislocation 
of the scaphoid forwards, caused by a direct blow upon the top of the 
foot. The scaphoid was completely separated from the cuneiform bones. 
The reduction was effected not without much difficulty. When the child 
left the hospital there still remained some deformity, the fo<»t being a 
little turned outwards; and the arch of the tarsus being somewhat 
flattened. 

8 eral examples are recorded of a true dislocation of the os scaphoi- 
des. in which the bone had abandoned botli tin- astragalus on the one 
hand, and the cuneiform bones on the other. 

Piedagnel mentions a case in which the scaphoid bone was broken 
longitudinally, and its internal fragment, constituting the largest portion, 
was displaced inwards through a tegumental^ wound. Be was unable 
to effect reduction, and was compelled to amputate the foot. 4 

Walker has reported an example of dislocation forwards, occasioned 
by jumping upon the ball of the foot. The bone formed a marked pro- 
jection upon the top of the foot, and a corresponding depression existed 
below. An attempt was first made to accomplish the reduction by sim- 
ple pressure with the thumbs; but this having failed, the surgeon t»<-nt 
the extremity of the foot forcibly downwards, and by continuing to | 

1 Burnett, Lond. Med. Gazette, - ' rix. p. 221. 

- Rizzoli. Clin. Cbir trad par Andreini, I' 16. 

Garland, Ai I '-' ;4 - 

4 Piedagnel, Jonrn. LTniv. ft Heb., torn ii. {> 



948 TARSAL DISLOCATIONS. 

upon the scaphoid, it fell into its position easily and with a distinct click. 
In about three weeks the patient was able to walk with only a slight 
halt, and do deformity remained. 1 

Robert \\\ Smith 8 has also reported a case of ancient dislocation of 
the scaphoid upwards, in a man who several years before had fallen from 
a horse, the toot being caught in the stirrup under the animal. The 
bone projected in front of the head of the astragalus; the sole of the 
fool was very much flattened, but walking was not at all interfered with. 

^ 7. Dislocations of the Cuneiform Bones. 

The cuneiform bones maybe dislocated without having separated from 
each other, of which two or three examples are recorded; or, which is 
more common, the internal cuneiform may be dislocated alone. Says 
Sir Astlov Cooper: "I have twice seen this bone dislocated; once in a 
gentleman who called upon me some weeks after the accident, and a 
Becond time in a case which occurred in Guy's Hospital very lately. In 
both instances the same appearances presented themselves. There was 
a great projection of the bone inwards, and some degree of elevation, 
from it> being drawn up by the action of the tibialis anticus muscle; and 
it no longer remained in a direct line with the metatarsal bone of the great 
toe. In neither case was the bone reduced. The subject of the first of 
these accidents walked with but little halting, and I believe would in 
time recover the use of the foot, so as not to appear lame. The cause of 
the accident was a fall from a considerable height, by which the ligament 
was ruptured which connects this bone with the os cuneiforme, and with 
the os naviculare. The second case, which was in Guy's Hospital, my 
apprentice, Mr. Babington, informs me happened by the fall of a horse, 
and the foot was caught between the horse and the curbstone." 3 

Villars 4 met with an example of dislocation of the cuneiform internum 
upwards and inwards, which he reduced by extension, abduction, and 
pressure on the second day; at the end of two months the patient could 
walk easily. 

In a case reported by Meynier 5 the dislocation of this bone was thought 
t<> be due to muscular contraction alone. The reduction was easily 
effected. 

Fitz-( ribbon 6 reports a case of dislocation of the internal cuneiform 
downwards and inwards, from a direct blow. Reduction was easily ac- 
complished by extension and direct pressure, and recovery took place 
without accident. 

Lemoine 7 met with a similar case in which reduction attempted on the 
nmotcnth day was found impossible. Four months after the accident 
the patient was able to walk, but not without fatigue. 

In B case of compound dislocation seen by Mr. Key, reduction was 

1 Walker, The Medical Examiner, 1851, p. 203. 

1 R. \V. Smith. Dublin Eospl Gaz., 1855, vol. ii. p. 76. 

Astley Qooper, <>\). cit., p. 383. 
1 Villare, Poulet, Gaz MeU <!<• Paris, 1851, p. 757. 
Meynier, Gaz Bfeo de Paris. 1851, p. 520. 

I bbon, Dublin Joura. Mod. Sci., 1877, vol. lxiv p. 271. 
: Lemoine, Rev. Mens. deChir, 1883, No. 2, p. 121. 



DISLOCATIONS OF THE CUNEIFORM BONES: 949 

effected, and in two months the cure was so far completed that the 
patient walked with only a slight lameness. 1 Nelaton, in a similar case 
of compound dislocation, unable to reduce the bono, removed it com- 
pletely, and the patient recovered. 2 

A dislocation of the second cuneiform has boon observed by Win. 11. 
Folker 3 and by B. Anger. 4 

In Folker*s case reduction was easily effected. In the case reported 
by Anger the dislocation was incomplete, not protruding more than one 
centimetre, but it could not be reduced. 

Robert Smith has called attention to a species of dislocation of the 
internal cuneiform bone not before very accurately described: but of 
which he has presented two examples. It consists in simultaneous dis- 
location of the metatarsus and internal cuneiform: that is to say, the 
first metatarsal bone, together with the internal cuneiform, is dislocated 
upwards and backwards upon the tarsus, carrying with it also the four 
remaining metatarsal bones. In both of the examples seen and recorded 
by him the dislocations were ancient, and no account could be obtained 
of the precise manner in which the accidents had been produced. The 
feet were foreshortened to the extent of an inch or more in consequence 
of the overlapping of the bones, yet the heel in each case preserved its 
natural relations to the tibia, not being proportionately lengthened as 
is the case in dislocations of the tibia forwards. The plantar surface of 
the foot was turned inwards, and instead of being concave it was convex. 
both in its antero-posterior and transverse diameters. A transverse ridge 
on the top of the foot also indicated the line of the projecting bones. Both 
of these cases were verified by a careful dissection. 5 

Dupuytren has reported in his Treatise on Injuries of the Bones, a 
similar case, occurring in a woman, ret. 39, who was brought immedi- 
ately to Hotel Dieu. She stated that in descending from the bridge of 
St. Michael, with a burden of two hundred pounds, she fell in sucb a 
way that the whole weight of the body was received on the right foot, 
and that, at the moment she made an effort to check herself in falling, 
she experienced extremely severe pain in this part, and heard a very 
distinct snap ; she was unable to raise herself from tin- ground. I Mi the 
following morning Dupuytren reduced the bones with very little diffi- 
culty by extension, combined with pressure against the dislocated ends. 
The bones went into place with a loud snap, and in two or three months 
she left the hospital, with only a little lameness/ 

Bryant ha- Been two cases of simultaneous displacement of the cunei- 
form internum and the corresponding metatarsal bone. 

Mr. Smith, without intending to question the possibility of :( simple 
dislocation of the. metatarsal bones, of which, indeed, Malgaigne has col- 
lected a number of well-authenticated examples, ia inclined to believe 
that, when a dislocation of the bones of the metatarsus is the consequence 

i Key, <• • B jp. i: i. p. 644. 

- N.'latou, Malgaigne, "i>. cit . p, : 

* Folker. Tli" Lancet, 1856, vol. ii | 

♦ A. Anger, Traitl, iconograpbique dea Malad. Chir., I' 

' Robert Smith, ] I' 1864, p. 224 el 

• Dupuytren. op. cit., {• 



950 MSLOCATIONS OF THE METATARSAL BONES. 

of :i fall from a height, the individual alighting upon the anterior part 
«>f the foot, it is. in general, that variety which has now been described. 
And this aptness on the part of the cuneiform bone to maintain its con- 
nection with the first metatarsal bone, he would ascribe mainly to the 
feci that both the peroneus longus and tibialis anticus have attachments 
to each of the hones in question. 

Dr. Bertherand, of Algiers, 1 in 1856 reported a case of simultaneous 
dislocation of all the cuneiform bones, without separation from the meta- 
tarsal bones, caused by a fall upon the sole of the foot. The dislocation 
was Dot reduced, and was only seen by Bertherand two years after the 
accident occurred. The foot was atrophied; the tarsal and metatarsal 
articulations were anchylosed, and he walked entirely on his heel. 



CHAPTER XXIY. 

DISLOCATIONS OF THE METATAKSAL BONES. 

Dislocations of one or more of the metatarsal bones, at the points of 
their articulations with the tarsus, have been known to occur in almost 
every direction. They may be occasioned by crushing accidents, or more 
often perhaps they have been caused by a fall backwards or forwards, 
when the anterior extremity of the foot was wedged under some solid 
body and immovably fixed. They may be produced, also, by alighting 
upon the ball of the foot when falling from a height. I have noticed, 
however, that Mr. Robert Smith inclines to the opinion that this will, 
in general, only produce the species of dislocation which he has particu- 
larly described, and to which reference has been made in the preceding 
chapter. 

The symptoms which characterize the dislocation of the whole range 
of metatarsal bones upwards and backwards will, when the dislocation 
i< complete, resemble very much those which belong to the dislocation 
described by Smith. The dorsum of the foot will be shortened antero- 
posteriorly, the two arches of the foot will be lost upon the plantar sur- 
face, or even actually reversed, a ridge will traverse the back of the 
foot and a corresponding depression will exist underneath. 

In some cases, however, the dislocation is not complete, the articula- 
tiona being only sprung, and then there can exist no foreshortening of 
the foot, and all the other signs will be less striking. 

If only a Bingle bone is dislocated, the diagnosis is generally very easily 
made out. unless, indeed, considerable swelling has already occurred. 

Mr. South says that, in 1835, a case was admitted to St. Thomas's 
Hospital, under Mr. Green's care, of dislocation of the last two metatar- 
sal bones, occasioned by the falling of a heavy chest upon the inside of 
the foot. " Upon the top of the foot was a large swelling before and 
below the outer ankle, and behind it a cavity in which two fingers 

1 Bertherand, Bull. Soc. de Chir. de Paris, 1856-57, t. 7, p. 361 



DISLOCATIONS OF THE METATARSAL BONES. 051 

could he easily buried, in consequence of the bases oi' the metatarsal 
bones having been thrown upwards and backwards upon the top of 
the cuboid." The reduction was accomplished with much difficulty by 
continued extension, and as the bones resumed their place a distinct 
crackling was heard. 1 

Liston reduced a dislocation upwards of the first metatarsal bone. 
Malgaigne mistook a dislocation of the fourth bone for a fracture, and 
did not attempt the reduction until the seventh day, when, after five 
successive trials, the head entered with a noise into its cavity. In a 
dislocation of the second, third, and fourth metatarsal bones, he also 
failed to detect the true nature of the accident until the tenth day, 
when he proceeded to attempt reduction, but failed. Inflammation, 
suppuration, and delirium followed, and the patient died on the forty- 
first day. Tufnell failed in a similar case, although his patient finally 
recovered with a not very useful limb. Malgaigne failed to reduce the 
bones also in a recent case of dislocation of the first four bones, although 
he used chloroform and diligently trieo! various means. The same 
writer has seen one example of ancient dislocation, which was not recog- 
nized by the surgeon by whom the patient was first seen. Monteggia 
reports a case of dislocation of the last two metatarsal bones, which was 
not at the time recognized. On the tenth day swelling commenced, and 
soon after the patient died in convulsions. 2 

Dr. W. C. Shaw, of Pittsburg, reports the case of a man 35 years 
old. who. falling from a height, " struck with all his weight upon a sharp 
edge of stone, striking upon the inner and under surface of the right meta- 
tarsal bones, dislocating the proximal end of the first metatarsal bone 
upwards, and apparently carrying the second with it." After several 
ineffectual attempts at reduction made by himself and other-, in which 
extension and direct pressure were employed, he succeeded finally by 
' k bending the foot to an acute angle on the inner surface, approximating 
the articulating surfaces of the dislocated bones, and quickly extending 
the foot." 3 

These references sufficiently illustrate the difficulty which surgeons 
have experienced in the reduction of these bones, when a portion only is 
displaced: a difficulty which is probably due to the fact that it is almost 
impossible to make extension upon a single metatarsal bone. \\ e might 
expect more from forced dorsal flexion, as advised in the case "1" the 
phalanges, and which was successfully practised by Shaw. Direct pres- 
sure upon the displaced head cannot be expected to accomplish much in 
these accidents, owing to the small amount of surface presented against 
which the force can he properly applied. 

If, on the other hand, all the hone- are dislocated ;it once, the reduc- 
tion is generally accomplished with ease by simple extension, combined 
with properly directed pressure. Bouchard and Meynier succeeded with- 
out difficulty in two cases of backward dislocation; Smyley was equally 
successful on the sixth day. in a case of dislocation downwards. Laugier 
reduced an outward dislocation of all the bom- by pressure and extension 



Note to < I Lrg., vol. ii. p. 266. 

M ilgaigne, op cit, p. 1077 i 
i Shaw, Pitteburg Med. Journ . 1882, p 801. 



952 DISLOCATIONS OF THE PHALANGES OF THE TOES. 

easily; and Kirk succeeded as well, in an example of the opposite char- 
acter, all the bones being carried inwards. 1 

Mr, Sandwitb lias given us an account of a case which occurred in 
his owd person, from the fall of his horse upon his foot. " I was in- 
stantly sensible." says Mr. Sandwith, "of the nature of the injury, and 
as soon as 1 was upon my feet, the metatarsus was found to be drawn 
upwards, and obliquely outwards upon the tarsus, by the action of the 
flexor muscles. On the removal of the boot, which was cut away, these 
were the appearances: The foot considerably shortened, the toes turned 
a little outwards, and a hard swelling, bigger than an egg, upon the 
tarsus, with tumefaction of the integuments. The pain, which was great 
at first, was kept under by a warm fomentation. 

•• The reduction was easily effected by my friends Messrs. Williams 
and Brereton, and leeches and bread-and-w r ater poultices prevented in- 
flammation. For several nights the foot was violently shaken by spas- 
modic action of the muscles, but the parts preserved their relative situa- 
tion: and although it was nearly a year before all lameness ceased, yet 
at the end of six weeks I was enabled to lay aside my crutches. For 
the ability to use the foot in so short a time, I was indebted to a con- 
trivance which rendered the foot and ankle inflexible. 

" Instead of an elastic sole to the shoe part of the apparatus, one of 
wood was procured, around the heel of which was nailed a piece of firm, 
unbending leather ; this reached as high as the calf of the leg ; three 
small straps with buckles held the leg in situ, and a broader one across 
the instep secured the foot. The comfort I experienced from this simple 
apparatus is my reason for describing it so particularly ; it has since been 
found useful in various injuries of the foot and ankle." 2 

In one extraordinary case, however, Dupuytren was not so successful. 
Paid Eudes, set. 24, fell, while drunk, into a ditch six feet deep, and 
alighted on the soles of his feet. The accident was followed by great 
swelling, and he did not suspect the nature of the injury, nor present 
himself at the hospital until three weeks after. Dupuytren then ascer- 
tained that he had dislocated the metatarsal bones of both feet. Several 
fruitless attempts were made to accomplish the reduction, but to no pur- 
pose, and in about two weeks he left the hospital. 3 



CHAPTER XXV. 

DISLOCATIONS OF THE PHALANGES OF THE TOES. 

DISLOCATIONS of the toes are less common than those of the fingers, 
yet a considerable number of cases have been recorded by different sur- 
geons. They are occasioned by blows received directly upon the ends 

eaigne, op. <-it.. p. 1081. 
Ddwith, Amer. J< .urn. Med. Sci., Nov. 1828, p. 216; from London Med. Gaz. 

v<.]. i. 

| lytrf-n, op. <:;.. p. 329. 



DISLOCATIONS OF THE PHALANGES OF THE TOES. 958 

of the toes: by the weight of the body brought to hear suddenly upon 
their plantar surfaces, as when a horseman springs in ltis stirrups, or by 
a fall, in consequence of which the rider hangs in his stirrup; by leap- 
ing, etc. 

They may be partial or complete; and in the latter case, a slight over- 
lapping is generally observed. In a great majority of cases the direction 
of the displacement is backwards, or with only a slight lateral deviation. 
Occasionally several bones are displaced at the same lime, hut usually 
only one suffers displacement. It is more common here to find compound 
and complicated dislocations than in the case of the fingers. 

The position of the toes is not always the same in the same form of 
dislocations. Thus, in the dislocation backwards, the toe is sometimes 
reversed upon the foot to nearly a right angle, and at other times it is 
found lying in the same axis as the metatarsal bone, or the phalanx, 
from which it is dislocated. Some years since I reduced a backward 
dislocation of the first phalanx of the second toe in the person of Lewis 
Britton, aet. 60. who had fallen from a fourth-story window, striking 
upon his feet, and breaking both thighs. I did not discover the dislo- 
cation of the toe until sixteen hours after the accident. It was then 
lying parallel with the axis of the metatarsal bone, upon which it was 
slightly overlapped. The reduction was effected easily by pulling upon 
the last phalanx with my fingers, while at the same moment I pushed 
the head of the bone toward the socket. No swelling followed, nor lias 
it troubled him at all since his recovery. 

Dr. John H. Packard, of Philadelphia, informs me that in a disloca- 
tion backwards of the first phalanx of the great toe, occurring in a very 
muscular man, the phalanges were found lying parallel with the meta- 
tarsal bone; and it was reduced easily by extension, while the patient 
was under the influence of ether. 

Treatment. — With regard to the treatment, surgeons have experienced 
the same difficulty, in certain cases of dislocation of the great toe, as we 
have seen experienced in similar dislocations of the thumb. Occasion- 
ally, indeed, the reduction has been found to be impossible, 'fhc same 
doubts have existed also in relation to the causes of this difficulty, and in 
reference to the means by which it was to be overcome. I shall there- 
fore refer the reader to the chapter on Dislocation- of the First Phalanges 
of the Thumb and Fingers, for a more full consideration of this matter. 

In case the smaller toes are dislocated, the reduction is generally 
effected with ease, by simple extension, or by extension combined with 
pressure; sometimes, also, the bone will be more easily put in place by 
reversing the phalanx more completely, as 1 have advised in certain 
cases of dislocations of the fiiiLfcr-. 

If the skin is penetrated, it will often be found necessary either to 
amputate or to practise resection upon the exposed phalanx. 

Sir Astley Cooper relates a case of dislocation of "all the smaller 
toes," from the metatarsus, which bad not been reduced, and the subject 
of which was. in consequence, so much maimed that he was unable to 
labor. It had been occasioned by ;< fall, from b considerable height, 
upon the extremities of the toes. A projection existed at the roots of 
all the smaller toes, the extremity of each metatarsal bone being placed 



954 COMPOUND DISLOCATIONS OF THE LONG BONES. 

under the first phalanx of its corresponding toe. The swelling which 
immediately followed the receipt of the injury had concealed its nature y 
and now, several months having elapsed, reduction could not be effected. 
The only relief which could be afforded him, therefore, was in wearing 
a piece of hollow cork at the bottom of the inner part of the shoe, to 
prevent the pressure of the metatarsal bones upon the nerves and blood- 
vessels. 1 



CHAPTER XXVI. 

COMPOUND DISLOCATIONS OF THE LONG BONES. 

Frequency of Compound as compared with Simple Dislocations. — 
Compound dislocations, as compared with simple, are of rare occurrence. 
Of ninety-four dislocations reported by Norris as having been received 
into the Pennsylvania Hospital for the ten years ending in 1840, only 
two were compound ; 2 and of one hundred and sixty-six dislocations in 
my record of personal observation made in 1855, only eight were com- 
pound. 3 

Relative Frequency in the Different Joints. — In my own recorded 
cases just referred to four were dislocations of the tibia inwards at the 
ankle-joint, one was a partial (pathological) dislocation forwards at the 
same joint, one a dislocation of the astragalus, one a dislocation of the 
head of the humerus into the axilla, and one a forward dislocation of the 
radius and ulna at the wrist-joint. I have also met with several examples 
of compound dislocations of the elbow and fingers. Both of the cases 
reported by Norris were dislocations of the thumb. 

Sir Astley Cooper, speaking upon this point, says that the elbow, 
wrist, ankle, and finger-joints are most subject to these accidents ; and 
that lie has seen but two in the shoulder-joint, and one in the knee-joint. 
II.- had never seen a compound dislocation at the hip-joint, and he 
believed thai it was " scarcely ever " so dislocated. Malgaigne says that 
a compound dislocation at the hip-joint has probably never occurred. 
Mr. Bransby Cooper has, however, reported in detail a very interesting 
case of this accident, communicated to him by Dr. Walker, of Charles- 
town. Mass., in which reduction was accomplished by manipulation alone, 
by Dr. [ngalls on the second day. The patient died at the end of about 
three weeks.' 1 have already, when considering dislocations of the femur 
don awards and backwards, referred to the case reported by Dr. W. Taylor, 
in which reduction having been effected recovery took place. 

Among the cases of compound dislocation recorded by Sir Astley and 

A.stley Cooper, op. cit. , p. 385. 
Norris, A.mer. Journ. Med. Sci., April, 1841, p. 335. 
■ For most of these cases, see Transactions of the New York State Med. Soc. for 
article entitled " Keport on Dislocations, with especial reference to their 
Result*," by F. H. Hamilton. 
4 A. Cooper, on Dislocations, etc., by B. Cooper, p. 59. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 9bd 

Bransby Cooper, most of which were communicated to these gentlemen 
by other surgeons, forty-five were dislocations of the ankle, ten iA' the 
astragalus, four of the ulna at the wrist-joint, four of the thumb, two of 
the knee, one of the shoulder, one of the elbow, one of the radius and 
ulna at the wrist, one of the scaphoid bone, and one of the metatarsal 
bone of the great toe. Other writers have occasionally described com- 
pound dislocations of the clavicle, but I know of no record of a compound 
dislocation of the lower jaw. 

Prognosis, as determined by the Mode of Treatment adopted by most 
of the Ancient and many of the Modern Surgeons. — By most of the 
early writers these accidents, whenever they occurred in the larger joints, 
were regarded as nearly beyond the reach of art. Says Hippocrates : 
''In cases of complete dislocation at the ankle-joint, complicated with 
an external wound, whether the displacement be inwards or outwards. 
you are not to reduce the parts, but let any other physician reduce them 
if he choose. For this you should know for certain, that the patient 
will die if the parts are allowed to remain reduced, and that he will not 
survive more than a few days, for few of them pass the seventh day, 
being cut off by convulsions, and sometimes the leg and foot are seized 
with gangrene." Hippocrates adds: "But if not reduced, nor any 
attempt at first made to reduce them, most of such cases recover." 1 

The same remarks are applied by Hippocrates to compound disloca- 
tions of the head of the tibia, of the lower end of the femur, of the 
wrist, elbow, and shoulder-joints ; death occurring in all cases, as he 
believed, more or less speedily whenever the bones are reduced and re- 
tained in place a sufficient length of time, and " were it not that the 
physician would be exposed to censure," he would not reduce even the 
bones of the fingers, since it must be expected, he thinks, that their 
articular extremities will exfoliate even when the reduction is most 
successful. 

I shall presently show, however, that even Hippocrates advised and 
probably practised resection in certain cases of these accident-. 

Both Celsus and Galen adopt almost without qualification the line of 
practice laid down by Hippocrates, and affirm equally the danger and 
almost certain death consequent upon the reduction of compound dislo- 
cations in large joints. 2 Celsus recommend- resection in some cases. 

Paulus iEgineta, however, and after him Albucasis, Haly Abbas, and 
Rhazes, do not regard the rules established by Hippocrates, in relation 
to the non-reduction of the bones, as so imperative, nor the results of the 
opposite practice as so uniformly fatal. 

••Hippocrates remarks," says Paulus iEgineta, "in the case of dislo- 
cations with a wound, the utmost discretion is required. For tie---, if 
reduced, occasion the mosl imminent danger, and sometimes death, the 
Burrounding nerves and muscles being inflamed by the extension, so that 
strong pain-, spasms, and amrc fevers are produced, more particularly 
in the case of the elbow.-, knees, and joint- above, for the Dearer they 
are to the vital parts the greater is the danger they induce. \N herefore, 

1 Works of Hippocrates, 8yd. ed., London, vol. ii. p 

2 Paulu- . 3yd. ed., vol. ii. p. 610. 



956 



COMPOUND DISLOCATIONS OF THE LONG BONES. 



Hippocrates, by all means, forbids us to apply reduction and strong band- 
aging to them, and directs us to use only anti-inflammatory and soothing 
applications to them at the commencement, for that by this treatment life 
may sometimes be preserved. But what he recommends for the fingers 
alone, we would attempt to do for all the other joints; at first and while 
the parts remain free from inflammation, we would reduce the dislocated 
joint by moderate extension, and if we succeed in our object, we may 
persist in using the anti-inflammatory treatment only. But if inflamma- 
tion, spasm, or any of the aforementioned symptoms come on, we must 
dislocate it again if it can be done without violence. If, however, we 
are apprehensive of this danger (for perhaps, if inflammation should 
come on. it will not yield), it will be better to defer the reduction of the 
greater joints at the commencement ; and when the inflammation sub- 
sides, which happens about the seventh or ninth day, then, having fore- 
told the danger from reduction, and explained how, if not reduced, they 
will be mutilated for life, we may try to make the attempt without vio- 
lence, using also the lever to facilitate the process." 1 

In the following quotations from three of the most celebrated writers 
of the last two centuries, we find but little if any evidence that the opin- 
ions of the fathers upon this subject were not still held in general re- 
Bpect: "If the joint be dislocated, so that it is either uncovered, or a 
little thrust forth without the skin, the accident is mortal, and of more 
danger to be reduced than if it be not reduced. For if it be not reduced, 
inflammation will come upon it, convulsion, and sometimes death. 2. 
There will be a filthiness of the part itself. 3. An incurable ulcer, and 
if perhaps it be brought to cicatrize at all, it will easily be dissolved by 
tea -on of the softness of it; but if it be reduced, it brings extreme dan- 
ger of convulsion, gangrene, and death." 2 

" Si vero in magnis articulis tarn valida fuit facta luxatio, ut liga- 
ment is ruptis os articuli multum sit protrusum per integumenta, haec 
pars ossis vasis privata moritur, citius autum si reponatur, quam si non 
reponitur; quare sola amputatio restat ad conservationem vitae." 3 

Heister, who makes no allusion to this subject in the first edition of 
his great work, published at Amsterdam in 1739, adds the following 
remarks in his last edition, translated and published in London in 1768 : 
•• Dislocations attended with a wound, especially of the shoulder or thigh- 
bone, arc of very bad consequence, and often endanger the life of the 
patient; in Celsus's opinion (Book VIII., Chap. XXV.), whether the 
bones be replaced or not. there is generally great danger, and so much 
tie- more the nearer the wound is to the joint. Hippocrates has declared 
thai no bones can be reduced with security, besides those of the hands 
and fret. ( Vectiar. 1!», 5.) See more on this subject in that passage of 
( lelsus jusl new quoted, though I by no means recommend the following 
liiiu implicitly." 4 

1 Paulufi dSgineta, 8yd. ed., vol. ii. p. 509. 

rurgeon'a Storehouse. By Johannes Scultetus, of Ulme, in Suevia. London 
ed . 1674, ]-. 81. 

■ Johannes de Gorter. Chirurgia repurgata. Lugduni Batavorem, 1742, p. 86. 

♦ General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768, 
vol. i. p. [fl4, 

8< also, •• De l'intervention Chir. dans lea lux. compliquees ducou-de-pied," by G. 
'iris, 1877. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 957 

Such were the extreme views as to the fatality of these accidents, and 
of the feebleness of our resources, entertained by the ancient, and even 
by the more modern writers almost down to our own day: with only rare 
exceptions these limbs were condemned either to great and inevitable de- 
formity, or to amputation. Nor, if we speak only of their fatality, have 
surgeons ceased to regard these accidents as among the most grave with 
which they have to deal. 

Pathology and Appreciation of the Sources of Danger as compared 
especially with Compound Fractures. — The danger, according to Sir 
Astley Cooper, consists in the rapid inflammation of the synovial mem- 
branes, which is speedily followed by suppuration and ulceration, whereby 
the ends of the bones become exposed: and for the repair of which 
lesions great general as well as local efforts are required, and a high de- 
gree of constitutional irritation results. In addition to which circum- 
stances, "the violence inflicted on the neighboring parts, the injury of 
the muscles and tendons, and the laceration of bloodvessels, necessarily 
lead to more important and dangerous consequences than those which 
follow simple dislocations." 

The sources of danger enumerated by Sir Astley Cooper have been 
regarded as sufficient to account for their extraordinary fatality by the 
majority of those, modern surgical writers who have alluded to the sub- 
ject ; but I must confess that to me they do not appear so. In compound 
fractures the mortality is far less ; yet one might naturally suppose that 
when the sharp and irregular fragments are pressing into the flesh, among 
nerves and bloodvessels, the irritation and inflammation would be equal, 
if not more than equal, to the irritation and consequent inflammation 
produced by exposing a joint surface to the air; indeed, modern expe- 
rience has sufficiently shown that these surfaces are much more tolerant 
of atmospheric exposure, and of the action of many other irritants, than 
surgeons formerly supposed. A clean incision into a large joint, which 
exposes the synovial membranes to the air, and which permits the pro- 
ducts of inflammation to escape freely, is attended with much less danger 
than a small puncture which does not at all permit the air to enter, nor 
the increased synovia and the pus to escape. Very grave results some- 
times follow from large wounds into large joints, hut under judicious 
treatment such results are the exception and not the rule.' But Sir 
Astley evidently attributes more of the had consequences to the exhaust- 
ing effects of the efforts at repair, than t<» the immediate inflammation 
resulting from the exposure of the joint. It i< pretty certain, however, 
that a majority of these patients die ;it ;i period too ''inly t<. render this 
cause in any considerable degree operative. 

As to the bruising of tie- "muscles and tendons, and laceration of 
bloodvessels," it cannot be denied that it must usually be greater than 
in "simple dislocations;" and I will not say thai it is not in a given 
number of instances greater than in the same number of instances of 
compound fractures. The tissues have often been thrusl rudely through 

1 Upon this point, see the very able article, entitled "Amputation! and Compound 

Fracture/' bv J' Journal of Medicine, v..]. iii. 

p. 316. Nov. 1849; and also a paper entitled •• De 1m conservation dam I" trail 

des fractures complquees," by <, P 



958 COMPOUND DISLOCATIONS OF THE LONG BONES. 

by a large and smooth bone, and the tendons have been stretched vio- 
lently or torn completely asunder; while occasionally large arteries, 
which arc prone to hug the bones about the joints, are lacerated and 
left to bleed. That the importance of these complications, however, may 
not be overestimated, I must state that Sir Astley Cooper himself has 
remarked how seldom, in compound dislocations of the ankle-joint, the 
large arteries are injured; that a tearing of the ligaments and of the 
tendons is almost as likely to occur in simple dislocations as in compound; 
and. indeed, that in neither case are the tendons usually ruptured, but 
only thrust aside. Moreover, the skin is often made to give way not so 
much from the pressure of the round head within, as from the equal 
pressure of some sharp angular body from without. In all these respects, 
there are many examples of compound fractures which possess not a whit 
of advantage; in which cases, nevertheless, the surgeon feels very little 
doubt as to the ultimate cure. 

In short, the causes which, according to Sir Astley Cooper, determine 
the extraordinary fatality of these accidents, do not sufficiently differ 
from those which operate in compound fractures to occasion so great a 
difference in results, and the fatality of compound dislocations remains 
unexplained; or if surgical writers have here and there intimated the 
true cause they have failed to give it its proper place and value. 

I think the cause of the greater fatality of compound dislocations over 
coin pound fractures is to be found in the simple fact that dislocations are 
generally reduced, and by splints or other apparatus successfully main- 
tained in place, while compound fractures, as my statistical report of 
cases has proven, are not generally reduced completely, nor can they by 
any means yet devised, except in a few cases, be maintained in place if 
reduced. Broken limbs, whether simple or compound in their character, 
will in a great majority of cases shorten upon themselves in spite of the 
most assiduous and skilful attempts to prevent it. 1 

In adults most bones break obliquely, and cannot be made to support 
each other, and even in transverse fractures the broken ends are gener- 
ally small compared with the articular ends of the same bones, and afford 
a very uncertain and inadequate support for themselves ; not to speak of 
the difficulty of once bringing their ends into exact apposition where the 
muscles are powerful, or where they lie embedded in a large mass of 
flesh so that they cannot be felt. While, on the other hand, dislocated 
loiics. whether simple or compound, are capable, when restored to place, 
of supporting themselves ; or with only slight assistance, their reduction 
may be maintained ; it is also ordinarily a work of no great difficulty to 
reduce them. 

Herein, then, consists the most important difference between these two 
classes of accidents, which are in other respects so similar. In the one, 
the very nature of the injury prevents the complete reduction, and the 
consequent violent strain of the muscles, tendons, and other soft tissues; 
while in the other, the nature of the accident leaves it in the power of the 
surgeon to reduce the bones, and modern surgery has in a great measure 



• Report OD Deformities after Fractures." 
. and x. 



Trans. Amer. Med. Assoc, vols. viii.. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 959 

sanctioned the practice of maintaining them in place, in defiance of the 
efforts of the muscles, and sometimes, no doubt, at the imminent hazard 
of the life of the patient. 

Is it not fair to presume that tissues which have been stretched and 
lacerated, require rest in order that they may recover from the effects of 
their injuries ? And if the soft parts are really more injured in disloca- 
tions than in fractures, does not the indication for rest become for this 
very reason more imperative ? 

treneral Inferences. — I have come, then, to regard the shortening 
of limbs after fractures, within certain limits and in certain cases, as a 
conservative circumstance rather than as a circumstance which the sur- 
geon should in all cases seek to prevent. 

There is abundant evidence that the ancients had some knowledge of 
the value of rest to the muscles, tendons, etc., in the prevention of inflam- 
mation after compound dislocations, since they constantly urge the greater 
danger of reducing these dislocations, than of leaving them unreduced ; 
and they do not hesitate to recommend that, in case violent inflammation 
supervenes upon the reduction, the bone shall immediately be again dis- 
located. Galen speaks very explicitly on this subject, and says that 
** the danger in reduction consists partly in the additional violence in- 
flicted on the muscles, and partly in their being then put into a stretched 
state, whereby spasms or convulsions are brought on, and gangrene as 
the result of the intense inflammation which ensues ;" and Paulus ^Egi- 
neta remarks: " For these, if reduced, occasion the most imminent dan- 
ger, and sometimes death ; the surrounding nerves and muscles being 
inflamed by the extension," etc. 

I have already quoted from Sir Astley Cooper the causes or reasons 
which he has assigned for the fatality of compound dislocations ; and 
the same reasons have generally been assigned by those who have 
written since his day; but he has elsewhere, when speaking of exsec- 
tion. given place to the very idea for which I claim so much promi- 
nence, the danger arising from a stretching of the muscles. Mr. Listen. 
also, and Mr. Miller, Avhen speaking especially of dislocations of the 
tibia at the ankle-joint, refer to the same source of danger. 

Treatment. — Let us see now the alternatives which surgery presents 
for the treatment of these intractable accidents. 

1. Reduction of the bone. 

2. Non-reduction. 

3. Amputation. 

4. Tenotomy. 

5. Resection and reduction. 

The questions for as to consider are, first, by which of these sereral 
methods is the life of the patient rendered mosl secure? and, second, 
where, of two or more methods, all are equally safe, by which will he 
suffer the Least maiming or mutilation '.' 

By Reduction. — We have Been already how the old surgeons regarded 
the practice of reducing compound dislocations of the larger joints. It 
is not difficult, however, to find in tie- records of surgery numerous 
amples of successful terminations under this practice. 

Dr. White, of Hudson, X. V.. has reported a case of this kind in 



960 COMPOUND DISLOCATIONS OF THE LONG BONES. 

which the dislocation was at the ankle-joint. 1 Pott says he has seen 
this practice occasionally succeed, 2 and Mr. Scott communicated to the 
Lancet, in March, 1837, a case of compound dislocation of the humerus 
successfully treated by reduction. Sir Astley Cooper also records several 
cases of compound dislocations at the lower end of the tibia and fibula, 
successfully treated by reduction. 

A careful examination, however, of those cases reported by Sir Astley 
as having been reduced without resection, and which resulted in cures, 
does not, in my opinion, leave much substantial evidence in favor of the 
practice ; or perhaps I ought rather to say that it leaves only a qualified 
evidence of its propriety in certain cases. He has mentioned about six- 
teen of these examples, comprising dislocations of the lower end of the 
tibia, or of the tibia and fibula, outwards, also inwards and forwards, all 
of which, save one quoted from Mr. Liston, have been reported to him 
by other surgeons, and not one of which had he ever seen himself. Many 
of the cases are reported very loosely, evidently in reply to circular let- 
ters, and from memory, without recorded notes, and by unknown, and in 
some sense irresponsible, surgeons. It is not always said whether the 
wounds in the soft parts were made by the protrusion of the bones, or "by 
some external violence ; yet this is certainly a very material point in 
determining whether reduction is to be followed by inflammation or not. 
The results, sometimes only attained after exposure to great hazards, are, 
after all, often sufficiently unfavorable. 

It will be noticed, also, that, in Cases 152 and 15-3, the astragalus 
was comminuted and removed, either at first or at a later day ; and in 
Cases 154, 155, 156, and 160, the tibia, and also probably the fibula, 
were broken, and it does not appear but that in consequence of this 
com plication the limb became shortened, and the muscles were thus put 
at rest, very much as if the bones had been resected ; and in one of the 
- enumerated under 161, the lower end of the tibia spontaneously 
exfoliated. That a comminution or that any fracture of the astragalus, 
or of the tibia and fibula, should be regarded in these cases as rendering 
the accident less grave, can only be comprehended by a full appreciation 
of the value of relaxation of the muscles. 

The few cases which remain after this exclusion do indeed illustrate 
how nature and skill may triumph over great difficulties, but nothing 
more. 

Ir is possible, also, that some of these examples of recovery after re- 
duction may admit of an explanation entirely consistent with my own 
views of the true source of the danger in these accidents, if indeed they 
do not tend actually to confirm my doctrines. I have myself seen several 
examples of complete recovery after reduction of compound dislocations 
at the ankle-joint, although resection was not practised; in one of which, 
all the tissues, or nearly all which suffered any injury, were completely 
torn asunder, and therefore wholly removed from the danger of which I 
have spoken. The example referred to is the following : On the 30th of 
October, L858, John Bourquard, set. 30, was caught in the tow-line of a 

1 White, Amer. Journ. Med. Sci., Nov. 1828, p. 109. 
Pott, Chirurg. Works, vol. ii. p. 243. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 961 

canal-boat, causing a compound dislocation of the right ankle-joint. I 
found the foot, immediately after the accident, thrown completely hack 
against the lower part of the leg, the integuments in front of the joint, 
as well as all of the tendons and ligaments on this side, being completely 
torn asunder, while the tendo Achillis, and the tendons behind both of 
the malleoli, with the corresponding integuments, were uninjured. This 
immunity of the tissues behind the malleoli w r as due to the direction in 
which the foot was drawn, namely, directly backwards. Everything 
which had suffered a strain being thoroughly severed, I did not hesitate 
to attempt to save the limb without resection. The reduction was accom- 
plished very easily. The leg and foot were placed in a box filled with 
bran, and cool water dressings were applied to the portion which was 
exposed. On the 22d of November the limb was removed from the bran 
to a pillow, the union being sufficient not to demand so much lateral sup- 
port. About the first of March he left the hospital, the wound having 
closed, but the ankle remaining swollen and stiff. 

I have also seen tw r o cases in wdiich the foot has been nearly severed 
from the leg through the ankle-joint, by means of a "reaper." In each 
case the patient was standing with his back to the machine, and one of 
the blades cut horizontally from side to side, severing everything except 
about three inches of integuments in front, and the extensor tendons of 
the toes. In the first instance, having seen the patient, a gentleman 
nearly sixty years of age, within three or four hours after the receipt of 
the injury, I found him exceedingly exhausted by the haemorrhage. Both 
malleoli were cut off smoothly, the knife having severed the limb so ex- 
actly through the joint, as to have incised the cartilage of incrustation at 
but one or two points. Having secured the bloodvessels, I replaced the 
foot, and after a few days of attendance I left him in the charge of an 
excellent young surgeon, Dr. Robertson, of Lancaster, N. Y., to whose 
diligence and skill the patient is no doubt mainly indebted for his recov- 
ery. After the lapse of nearly one year he was able, by the assistance 
of a shoe furnished with lateral supports, to w r alk very well. In the 
second case, which was only brought to my notice some months after the 
accident occurred, in consequence of a troublesome fistula near the ankle- 
joint, the recovery had been complete except that a small fragment of one 
of the malleoli was necrosed and required removal. 

Dr. Eli Hurd. of Niagara Co., X. V.. was equally fortunate in ;i case 
of compound dislocation of the shoulder-joint. This was m the person 
of G. T., set. 30. who was caught in the gearing of a threshing-machine 
on the 18th of February, 1852, which, having drawn him in with great 
force, dislocated the head of the left humerus downwards througfi tli<' 
integuments into the axilla. Reduction was accomplished according t<> 
the method recommended by Nathan Smith, by pulling from each wrist 
at right angles with the body, while the operator himself seized the 
naked head of the humerus with In- lefl hand, bis righl resting upon the 
top of the shoulder, and pushed it into place. Tin' tunc occupied in the 
reduction was about thirty seconds. The forearm was then suspended 
in a sling, and the venous haemorrhage, occasioned hy ;i rupture of the 
subclavian vein, was arrested by compression. Tin- tegumentary wound, 
between three and four inches in length, was subsequently closed by 

61 



962 COMPOUND DISLOCATIONS OF THE LONG BONES. 



sutures, and cool water dressings were applied. On the fourth day the 
wound had united by first intention, and the man was walking about his 
room. In less than a month lie was dismissed cured, and in the follow- 
ing harvest he was able to cut his own hay and grain, and to use his arm 
as before the accident. 1 

Miller and Hoffman reduced successfully a compound dislocation of the 
knee.- and Gralli has communicated a similar case to Malgaigne. 3 

Whether either of the last three mentioned examples admit of the 
same explanation as the preceding three, I am unable to say, but whether 
they do or do not, they are too exceptional in their character to preju- 
dice materially the argument which I shall hereafter make in favor of 
resection. 

It is not pretended that the few cases which I have mentioned in the 
preceding pages are all of the compound dislocations of the larger joints, 
successfully treated by reduction, which have been recorded ; nor are they 
all which have come under my own observation ; nevertheless, I repeat, 
success by this method has up to this moment, whatever plan of after- 
treatment has been adopted, been found to be the exception and not the 
rule. I speak now more especially of those dislocations of this class, 
which are rendered compound by the thrusting of the dislocated bone 
through the flesh, and which, in my experience, constitute by far the 
largest proportion of these examples. 

X<>n-r eduction. — While it is true that not many cases of compound 
dislocations, especially of the larger joints, can be found recorded as 
having terminated favorably after reduction, yet it will be very difficult 
to find an equal number of cases of compound dislocations, unreduced, 
which have terminated favorably. The fact is, no doubt, that at the 
present day very few surgeons would feel themselves justified in leaving 
a bone out of place unless they proceeded to amputate. In the Trans- 
actions of the New York State 31edical Society for 1855, 1 have reported 
(Case 16 of Tibia and Fibula, p. 87) a compound dislocation at the ankle- 
joint, which, being unreduced, terminated fatally on the twenty-eighth 
day. This is the only example of a compound dislocation of a long bone, 
left unreduced, which has fallen under my observation ; excepting, of 
course, those cases in which amputation was immediately practised. 

The united testimony, however, of the old surgeons, who generally 
neither amputated nor adopted the method of resection, but who recom- 
mended and practised non-reduction, is, that it is much more safe to 
have these hones unreduced, than to reduce them without resection; and 
I see no reason to doubt the correctness of their opinions in this matter. 
But whether it would be more safe to leave such limbs unreduced, or 
haying practised resection to restore them, is another question, in which 
the advantage and comparative safety of the latter practice are too obvious 
to require explanation or defence. 

Amputation. — Says Pott: "When this accident (dislocation of the 
ankle; is accompanied, as it sometimes is, with a wound of the integu- 

1 Said, Buffalo Med. Journ., vol. ix. p. 119. 

1 Miller and Hoffman, London Med. Kepos., vol. xxiv. p. 346. 

3 Galli, Malgaigne, op. cit.. torn. ii. p. 958. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 963 

ments of the inner ankle, and that made by the protrusion of the bone, 
it not unfrequently ends in a fatal gangrene, unless prevented by timely 
amputation, though I have several times seen it do very well without." 
And Sir Astley Cooper, speaking of compound dislocations of the ankle- 
joint, remarks: "Thirty years ago it was the practice to amputate limbs 
for this accident, and the operation was then thought absolutely neces- 
sary for the preservation of life, by some of our best surgeons." Nor 
is it difficult to see by what reasoning surgeons of "thirty years ago " 
had fallen back upon this desperate remedy. Both reduction and non- 
reduction having proven eminently hazardous, in the absence of perhaps 
both knowledge and experience in resection, they finally adopted the 
alternative of amputation, as that which after all must give to the patient 
the best chance for life ; and were no other alternatives to be presented, 
this would be my choice in a large proportion of cases. 

It must not be understood, however, that amputation is an expedient 
wholly free from danger; or, indeed, that the chances of the patient 
are in the average very greatly increased by this practice. Of thirteen 
amputations made for compound dislocations at the ankle-joint, in the 
Royal Infirmary at Edinburgh, only two resulted in the recovery of the 
patients. 1 Alluding to which, Mr. Fergusson remarks: "An amount of 
mortality which may well incline the surgeon to act upon the doctrine 
inculcated by Sir Astley Cooper" (to attempt to save the limb by re- 
duction). But Mr. Fergusson has added a sentiment which accords very 
closely with my own experience and opinions. "I fear, however, that 
in the attempts which have been made to save the foot (by reduction), 
the results in all the cases have not met with the same publicity — that 
the instances where amputation has been afterwards necessary, or where 
death has been the consequence, have not always been recorded: and. 
from what I have myself seen, I w r ould caution the inexperienced prac- 
titioner from being over-sanguine in anticipating a happy result in every 
example." 

By Tenotomy. — As a means of overcoming the resistance of the mus- 
cles, and for the purpose especially of facilitating the reduction, tenotomy 
has been proposed. First by Dieffenbacb in cases of ancient unreduced 
dislocations; but Wm. Hey. Jr., was the first to make a practical applica- 
tion of this suggestion in a case of compound dislocation. After cutting 
the tendo Achillis, the ankle being dislocated, the reduction was easily 
effected, but a strong tendency to displacement backwards remained, and 
he was obliged afterwards to cut the tendons of the tibialis posticus and 
flexor longus digitorum. 2 

This method, based in some degree upon a very correct notion of the 
principal sources of difficulty. I regard as in most ra<c- totally imprac- 
ticable, at Least to any useful or adequate extent. In order to be efficient, 
usually, all the tendon- passing the articulations must be cut, or nearly 
all of them; and 1 doubt whether the judgment of any discreet surgeon 
will ever sanction such an extreme measure. Nor do I think that in 
the point of view in which I am now considering this subject, baying ref- 

1 Edinb. Med. Monthly, A.ug. 1844. 

- Hey. Trans. ofProvinc. Med. and Surg I *ii. p. 171, 1844. 



964 COMPOUND DISLOCATIONS OF THE LONG BONES. 

erence only to the question of danger, if the cutting of the tendons was 
sufficiently extensive to have any real effect in facilitating the reduction, 
the practice would be found to have any advantage over other methods 
known to be eminently dangerous. Certainly in no case would the 
Burgeon, in my opinion, be justified in cutting any other than the tendo 
A chillis. 

By Resection. — Finally, resection presents itself for our consideration 
as the only remaining surgical expedient. 

We have seen that most of the early writers understood the effects of 
a constant strain upon the muscles in increasing the danger of spasms, 
inflammation, and death ; but in general they have suggested no remedy 
hut non-reduction or amputation. Hippocrates, however, uses the fol- 
lowing language, after speaking of resection of protruding bones in acci- 
dental amputations or in fractures of the fingers: " Complete resection 
of bones at the joints, whether the foot, the hand, the leg, the ankle, the 
forearm, the wrist, for the most part, are not attended with danger, 
unless one be cut off at once by deliquium animi, or if continued fever 
supervene on the fourth day." To which passage the translator adds 
the following note: "This paragraph on resection of the bones in com- 
pound dislocations and fractures contains almost all the information on 
the subject which is to be found in the works of ancient medicine." 
Celsus notices the practice of resection in compound dislocations very 
briefly, as follows: " Si nudum os eminet, impedimentum semper futurum 
est; ideo quod excedit, abscindendum est." 

Mr. Hey, of Leeds, was the first of modern surgeons who called espe- 
cial attention to the value of resection in compound dislocations. 

Subsequently, Mr. Parks, of Liverpool, in an "Account of a New 
Method of treating Diseases of the Joints of the Knee and Elbow," 
advocated the practice of resection in certain cases of diseases of these 
joints, but especially in "affections of the joints produced by external 
violence." 

M. Leveille, in France also, following, as he affirms, the guidance of 
Hippocrates, has advocated a similar practice. 

Yelpeau, Syme, Fergusson, Erichsen, Miller, Liston, Chelius, Lizars, 
Gibson, Norris, under certain circumstances, and especially where the 
bones cannot otherwise be reduced, and where the dislocations occur in 
certain joints, and especially the elbow and ankle-joints, recommend 
resection. To which names I may add that of Sir Astley Cooper, 
who lias considered the subject, as applied to the ankle-joint, quite at 
Length, and who says: "I have known no case of death when the ex- 
tremities of the hone" (tibia, at the ankle) "have been sawed off, 
although I shall have occasion to mention some cases which terminated 
fetally when this was not done." 

Why resection should diminish the danger to life, by placing at rest 
the injured muscles, has been already sufficiently considered; but it 
Beems not improbable that, if the synovial membranes are actually more 
susceptible of violent and dangerous inflammation than the other tissues 
about the joints, then would this source of danger be removed just in 
proportion as the synovial membranes themselves are removed. Such, 



COMPOUND DISLOCATIONS OF THE LONG BONES. 9H5 

indeed, was the argument used by Sir Astley : and Mr. South, in a note to 
(Thelitis, when referring to this fact, has made the following statement : 

"In compound dislocations of the ankle-joint, with protrusion of the 
shin-bone through the wound, most English surgeons saw off the joint 
end. not merely to render reduction more easy, but also, according to 
Sir Astley Cooper's opinions, to lessen the suppurative process, by 
diminishing the synovial surface. This mode of practice is certainly 
not commonly followed in reference to other joints, and the younger 
Cline was always opposed to its being resorted to in dislocated ankle." 

The following cases having occurred under my own eye. will serve 
to illustrate the value of the principle which I have been endeavoring 
to establish : 

Samuel Adamson, of Buffalo, set. 24. was caught by the cable of a 
vessel, June IT, 1855, dislocating the left tibia at its lower end inwards, 
and breaking the fibula two inches above the ankle. I was immediately 
called, and found the tibia protruding through the skin about three inches. 
Tbe periosteum was torn up, and the cartilaginous surface of the end 
of the bone was roughened. His thigh was also severely bruised and 
lacerated, but the bone was not broken. 

Dr. Boardman assisting me, we attempted to reduce the bones, but 
with our hands we found it impossible to do so. I proceeded imme- 
diately to remove about one inch and a half of the loAver end of the 
tibia with the saw. The remaining portion was then brought easily 
into place, and the wound dressed with sutures, adhesive strips, bandages, 
and light splints. On the same day he became an inmate of the marine 
wards at the Hospital of the Sisters of Charity, and was placed under the 
care of Dr. Wilcox, through whose politeness I was permitted to see him 
frequently. 

The wound in the leg healed kindly, with only a slight amount of 
inflammation and suppuration. Violent inflammation, however, occurred 
in the thigh, followed by extensive suppuration and sloughing. This, in 
fact, proved to be by far the most serious injury, and that which most 
endangered his life and delayed his recovery. 

After about two months, the ankle was in such a condition as to re- 
quire little or no further attention. The fragments of the fibula had 
shortened upon each other and were united, so thai the tibia rested upon 
the astragalus. It was nearly two months, however, before he began t<> 
walk, owing to the condition of his thigh. 

August 24, 1856, fourteen months after the accident. Adamson culled 
at mv office. Ho was then employed again as a sailor on board the 
schooner Sebastopol, ami performed all the duties of an ordinary deck- 
hand. His leg is shortened one inch and a quarter; from which it 
seems that there has been some deposil upon the end of the bene, which 
has compensated for one quarter of an inch of that which I removed. 
The ankle is perfect in it- form, being neither turned to the righl nor to 
the left, and he treads square and firm upon the sole of his foot. There 
is considerable freedom of motion, especially in flexion and extension. 
Occasionally it become a little swollen and painful. 

January 1, Wo. Rosanna Wilbur, aet. U>, was admitted to ward 18, 
Bellevue Hospital, having just been injured by :i street-car. She was in 



966 COMPOUND DISLOCATIONS OF THE LONG BONES. 



good health, but very fat, weighing 185 lbs. She was found to have a com- 
pound dislocation at the right ankle-joint — the tibia being thrust com- 
pletely through the flesh — and also a fracture of the fibula. Dr. Lewis, 
the house surgeon, reduced the dislocation at once, and easily, and then 
Bent for me. I advised an attempt to save the limb without resection, 
and by supporting the limb with the plaster-of-Paris dressing. This 
d rosing was applied fourteen hours after the accident by Dr. Lewis, a 
window being made opposite the ankle. January 3, the window was 
enlarged. January 5, gangrene and phlebitis had occurred ; fenestra 
again enlarged. January 7, entire splint laid open, and hot-water dress- 
ings applied. January 12, suspended limb. January 21, the condition 
of the limb very critical ; and, in a consultation composed of the visiting 
surgeons, we were equally divided between amputation and resection. 
It was permitted, therefore, that I should choose my own course. I 
immediately resected two inches of the lower end of the tibia, and placed 
the limb again in a sling supported with compresses as means of lateral 
support, and warm-water dressings were continued. The subsequent 
progress of the case wa* very slow, and there were several smart attacks 
of erysipelas, so that her life was at times in danger ; but finally all 
unfavorable symptoms disappeared, and on the first of May, the ankle 
was in perfect shape, admitting of some flexion and extension, and the 
wounds were almost completely closed. It is now apparent, that a re- 
section on the first day would have been the most judicious practice, but ' 
that even at a later day it saved her life. 

In a case of compound dislocation of the upper end of the humerus, 
occurring also under my own observation, and recorded in the Transac- 
tions of the New York State Medical Society for 1855 (p. 27, Case 14), 
in which reduction was followed by death, I have now much reason to 
believe that if I had practised resection before the reduction, my pa- 
tient's chances for recovery would have been greatly increased ; perhaps 
also the case of compound dislocation of the wrist-joint recorded in the 
same volume (p. 68), in which, having reduced the bones, I was subse- 
quently compelled to amputate, may equally illustrate the hazard to 
which the practice of reduction without resection must often expose the 
patient. 

The same remarks I will venture to apply to the case of compound 
dislocation of the hip, of which I have already spoken as having occurred 
in the practice of Dr. Walker, of Charlestown, Mass. Had the head of 
the femur been resected before its reduction, I cannot doubt but that the 
unfortunate man's ehance for recovery would have been very greatly 
improved. 

Thus, if we consider the question of the life of the patient only, the 
argument and the testimony seem to favor resection, in a great majority 
of case- of compound dislocations occurring in large joints, and in a con- 
siderable number of cases of similar accidents in the smaller joints. It 
is certainly more <;il'e than non-reduction or reduction without resection, 
and it is probably quite as safe as amputation. 

Poinsot, who has collected 82 reported cases of immediate resection 
practised for compound dislocations of the ankle-joint, found 68 cures, 



COMPOUND DISLOCATIONS OF THE LONG BONES. 067 

1<» deaths, and 4 secondary amputations, of which latter one was cured, 
two died, and the result in the fourth was unknown. 

But there is another question, which is. in my estimation, secondary 
to the one now considered, but which is often in the estimation of the 
patient himself of the first importance, namely, by which method will he 
suffer the least maiming or mutilation ? 

This question I do not find it difficult to answer. Certainly ii is not 
by non-reduction or by amputation : and. putting tenotomy aside, ii is 
now a question only between reduction without resection, and reduction 
with resection. These two methods, one of which experience has shown 
to be fraught with danger, and the other of which experience has shown 
to be relatively safe, are now to be compared in a point of view in which 
their antagonisms are perhaps less conspicuous, yet sufficiently marked. 

First. In either case the inflammation consequent upon the injury may 
be violent, and the recovery slow and tedious. The same arguments, 
however, which I have applied to the question of the comparative dan- 
ger of the two modes, must apply with nearly equal force to this question 
of maiming : since the amount of maiming must often be governed by 
the intensity and duration of the inflammation, and upon this point the 
testimony has been shown to be in favor of resection. 

It will be observed that not only is the danger of maiming rendered 
more considerable by reduction without resection, because the inflam- 
mation is so much more likely to extend to the tendons and muscles, 
causing them to adhere to each other, and to become subsequently atro- 
phied, a condition from which they often never completely recover ; but 
also because the ligaments and capsules of the joints, with the synovial 
surfaces, are in consequence encroached upon, and the freedom of motion 
is ever afterwards greatly restricted, if not completely lost. This marked 
impairment of the functions of the joint does not always happen, but it 
cannot be denied that it does generally. Indeed, it is by no means un- 
common for these accidents to be followed, after ulcerations of the carti- 
lage, by copious bony deposits in and around the joint-. 

How is it. on the other hand, with these joint., after resection? I 

have thus far heard of no cases in which complete anchylosis resulted : 

but in all considerable freedom of motion has returned, and in some the 

ration in this respect has been Dearly or quite as complete as before 

the accident. 

Poinsot has also made ;< very careful rhumi of the results of resection 
in regard to the usefulness of the limb. In 41 cases where the patients 
have been seen after complete recovery there is not ;i single failure : only 
it is observed that in the case of Oilier, there existed ;i slighl deviation 
of the foot backwards, which was corrected by apparatus. In all of these 
cases tin- patients walked well, and were able to resume their previous 
occupations. 

A similar analysis made by the same writer, of examples treated by 
reduction and wit), our resection, gave the following results: In 19 of 28 
cases, the patients could walk without artificial support : in one case the 
aid of a cane or of other support was required; three tme- tli<- foot was 
anchylosed in a vicious position, and remained painful, and til*' pat 
were obliged to ask for surgical interference; in two of these latter i 



968 COMPOUND DISLOCATIONS OF THE LONG BONES. 

amputation "was practised, and in one resection, the resection restoring to 
the patient a useful limb. 1 

Says Dr. Kerr, of Northampton: "Several cases of compound dis- 
location of the ankle have fallen under my care, and it has been uni- 
formly my practice to take off the lower extremity of the tibia, and to 
lav the limb in a state of semiflexion upon splints; by this means a great 
degree of painful extension and the consequent high degree of inflamma- 
tion arc avoided. The splints I used are excavated wood, and much 
wider than those in common use, with thick movable pads stuffed with 
wool. I keep the parts constantly wetted with a solution of liquor am- 
nionic acetatis, without removing the bandage. In my very early life, 
upwards of sixty years ago, I saw many attempts to reduce compound 
dislocations without removing any part of the tibia ; but, to the best of 
my recollection, they all ended unfavorably, or, at least, in amputation. 
By the method which I have pursued, as above mentioned, I have 
generally succeeded in saving the foot, and in preserving a tolerable 
articulation. " 

Sir Astley Cooper has made a valuable experiment to determine the 
condition of the new joint under these circumstances ; and the vast 
number of examples in which resection has now been practised in cases 
of caries of the articulating surfaces, and their results, add still more 
substantial proofs as to the usefulness of the joints after such opera- 
tions. 

" I made an incision upon the lower extremity of the tibia, at tlje inner 
ankle of a dog, and, cutting the inner portion of the ligament of the 
ankle-joint, I produced a compound dislocation of the bone inwards. I 
then sawed off" the whole cartilaginous extremity of the tibia, returned 
the bone upon the astragalus, closed the integuments by suture, and 
bandaged the limb to preserve the bone in this situation. Considerable 
inflammation and suppuration followed ; and in a week the bandage was 
removed. When the wound had been for several weeks perfectly healed, 
I dissected the limb. The ligament of the joint was still defective at the 
part at which it had been cut. From the sawn surface of the tibia there 
grew a ligamento-cartilaginous substance, which proceeded to the surface 
of the cartilage of the astragalus to which it adhered. The cartilage of 
the astragalus appeared to be absorbed only in one small part ; there was 
no cavity between the end of the tibia and the cartilaginous surface of 
the astragalus. A free motion existed between the tibia and astragalus, 
which was permitted by the length and flexibility of the ligamentous sub- 
stance above described, so as to give the advantage of a joint where no 
synovia] articulation or cavity was to be found. This experiment not 
only shows the manner in which the parts are restored, but also the ad- 
vantage of passive motion; for, if the part be frequently moved, the 
intervening substance becomes entirely ligamentous; but, if it be left 
perfectly at rest for a length of time, ossific action proceeds from the ex- 
tremity of the tibia into the ligamentous substance, and thus produces an 
ossific anchylosis." 

Second. I- it not probable, moreover, since the limb can be retained 

1 Poinsot, op. cit., p. 1238. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 969 

in place so much more easily after resort ion. that it will actually, in a 
majority of cases, he found to have been retained in place more per- 
fectly ? Even after simple dislocations, especially in those occurring 
at the ankle-joint, great deformity and much maiming arc the not un- 
frequent results, and that, too. when all diligence and care have been 
employed. It has been impossible always to maintain a perfect apposi- 
tion in the articulating surfaces. How much greater must be this diffi- 
culty in cases of compound dislocations. 

Third. The only argument which remains in favor of reduction with- 
out resection is the necessary shortening of the limb after resection. 
But this need seldom perhaps exceed three-quarters of an inch, and 
often not more than half an inch; an amount of shortening which, as 1 
have had occasion to prove when treating of fractures, does not neces- 
sarily produce a halt, and which indeed is often not known to exisl by 
the patient himself. It is claimed that the experience of Heine. Lan- 
genbeck, Volkman, Hueter, and other German surgeons, has shown that 
in a considerable number of cases, when these resections have been made 
by the subperiosteal methods, no shortening whatever has resulted. 1 

Finally. It must not be inferred that the author intends to recom- 
mend resection as a universal practice in cases of compound dislocations 
of the long bones. He has only sought to determine in a general 
manner its relative value as compared with other modes of procedure : 
and especially has it been his intention to bring more prominently into 
view the importance of rest and relaxation to the muscles, as an element 
in the treatment most essential to success. To declare its special appli- 
cation to cases would demand a treatise more elaborate than it was 
proposed to write. If, however, one were to speak of the individual 
bones only, there seems sufficient authority in the facts and arguments 
already presented, to conclude that resection is applicable to certain 
compound dislocations of the clavicle, humerus, radius, and ulna, fingers, 
femur, tibia, fibula, and toes ; in short, to a certain proportion of all these 
accidents occurring in the long bones of the extremities. 

If an attempt is made to save the limb without resection, it is scarcely 
necessary to say that the success will depend, in a groat measure, upon 
the care!! attention, and skill bestowed upon the treatment. The limb 
must be maintained in a position of rest, combined with moderate eleva- 
tion ; and warm water or other suitable dressings assiduously applied ; in- 
cluding a judicious employment of antiseptic precautions and of drainage. 

1 On Subperiosteal Resection of the Tibio-tarsal Articulation. V>\ Achilla 
M.D., New York. The Medical Record, July 8, 1876. 



970 



CONGENITAL DISLOCATIONS. 



CHAPTER XXVII. 



CONGENITAL DISLOCATIONS. 



§ 1. General Observations and History. 

I HAVE omitted, until this moment, to speak of Congenital Disloca- 
tions, because, whatever theory of causation we adopt, dissections have 
shown that they are generally, in some sense, pathologic, or are accom- 
panied with such essential modifications of the anatomical structures as 
to separate them entirely from ordinary traumatic dislocations, which 
alone constitute the proper subjects of consideration in the present treatise* 
In relation to congenital dislocations, we shall find it necessary to estab- 
lish systems of etiology, symptomatology, prognosis, and treatment, 
having very few points in common with traumatic dislocations. Excep- 
tions to this rule will occur, in examples of intrauterine traumatic disloca- 
tions, existing at birth without either original or accidental malformations 
of the articulations, or of the adjacent muscular, tendinous, or ligamen- 
tous structures; yet only in sufficient numbers to warrant the intrusion 
of the subject in this place. 

It is probable that congenital displacements may occur in all the artic- 
ulations of the skeleton ; and in most of them their existence has been 
already established by dissections. Until within a few years, however, 
the attention of surgeons has been almost entirely directed to congenital 
dislocations of the shoulder and hip. 

Hippocrates, in his treatise "De Articulis," speaks expressly of dislo- 
cations of the hip occurring in the mother's womb, comprising them under 
the same order with the different varieties of club-foot. 

Aviconna and Ambrose Pare have each mentioned congenital disloca- 
tions of the hip; but the first to record an example with any degree of 
accuracy was Kerkring; in which case, death having occurred during 
infancy, lie was able to verify his opinion by an autopsy. Chaussier has 
reported, in the Bulletin de la Faculte et de la Societe de Medecine, 
An. 1811 and 1812, the case of an infant, upon which he discovered, at 
birth, two dislocations, one at the scapulo-humeral articulation, and the 
other at the coxo-femoral. In 1788, Palletta, of Milan, published, under 
the title of Adversaria Chirurgica, a collection of observations, in which, 
among other things, Ik.- has described certain congenital malformations 
of tin- hip-joinl : and in 1820 he published another work, entitled Exer 
citationes Pathologicce, where he enters into a more complete exposition 
of the nature and causes of these deformities. 

In 1826, Dupuytreo read, before the Academy of Sciences, a memoir 
upon the lameness produced by the original displacement of the femur; 
and in the Lefons Orates, published in the collections of the Sydenham 
Society, may be found a full record of the views and observations of this 
distinguished >urgeon. 



ETIOLOGY. !>71 

The writings of Dupuvtren seem, more than anything previously writ- 
ten, to have directed the attention of sum-eons and pathologists to this 
interesting subject, and to have given a new impulse to investigation. 

From this time various treatises have been written by eminent surgeons, 
many of which are characterized by profound thought, careful investiga- 
tion, and practical experiment. 

Among those who have furnished us with elaborate treatises, or with 
more precise practical information upon this subject, the following names 
deserve to he especially mentioned: Bresc-het. 1 Caillard-Billioniere,* 
Lehoux. 3 Sandiforte, 4 Bouvier, 5 Sedillot. 6 Wrolik, 7 Guerin, 8 Parise, 9 
Pravaz pere, 10 Carnochan, 11 Robert Smith, 12 Delpech. 13 Heine. 14 von 
Amnion. 15 Pravaz fils. 16 Hueter, 17 Dollinger, 18 Grawitz, 18 Kirmisson, 80 
Kronlein. 21 Gerdy, 22 Poliniere, 23 Jalade-Lafond. 24 Humbert ami Jac- 
quier. 25 

^ 2. Etiology. 

Hippocrates says that the bones of the extremities may be disarticu- 
lated during intrauterine life by falls or blows, or by injuries of any 
kind, inflicted directly upon the abdomen of the mother. 

Ambrose Pare, while admitting the efficiency of the several causes 
named by Hippocrates, believed also that the contractions of the womb, 
and violence employed by the accoucheur, were occasionally adequate to 
the production of the same result. He taught, moreover, that the posi- 

1 Breschet, Repertoire d'Anatomie et de Physiologic Gaz. Med., Paris. 1884, p. 
218. 

2 Caillard-Billioniere, These Inaugurate, 1828. 

3 Lehoux, These Inaugurate, 1834. Paris. 

4 Sandiforte. Thesis, sustained before the Faculty of Med. of Ley den, 1886. 

5 Bouvier. Malad. Chron. de ap. Locomot, Paris, 1858. 

6 Sedillot,' Journ. de Connais. Med.-Chirurg., 1838. 

7 Wrolik, Amsterdam, 1839, quoted by Pravas. 

8 Guerin, Recherches sur les Luxations Congenitales ; par Jutes Gin'riii. Paris, 
1841. 

» Parise, Arehiv. Gen. de M<-d., 1842. 

10 Pravaz p^re, Traite Theoriqueet Pratique de- Luxations Conggnitales du Femur, 
suivi dun Appendice sur la Prophylaxie des Luxation- Spontaneea; par Ch. <i. 
Pravaz. Lyons, 1847. 

11 Carnochan, A Treatise on the Etiology. Pathology, and Treatment of Congenital 
Dislocations of the Head of the Femur; by John Murray Carnochan, X<\\ York, I860. 

11 It. Smith. A Treatise on Fractures in the Vicinity of ■ on Certain 

Accidental ami Congenital Dislocations. Dublin, 1864. 

13 Delpech. Orthomorphie, Pari-, 1829, t. 2. 

M Heine, Spont. und Uongen. Lux.. Stuttgard, 1842. 

15 Von Ammon, Die Angebornen Chir. btrankheiten der Blenschen, etc., Berlin, 
1842. 

16 Pravas :' gen. du Femur, Lyon, 1847. 

11 Hueter, Klin, der Gelenkkrankheiten, Leipzig, 1870 71. 
« I) lin ■ r, Arch. f. Klin. Chir., Bd. 20, 1877. 

19 Grawitz. Virchow'a Arehiv, Bd. 74, lift. 1, p. 1, IS 

20 Kirmisson, Rev. Hen. ■ 01 ii 

21 Kronlein. Die Lf-hre von d<-r Lux.. Deutsche Chir., v. Billrotk I. 1882. 

22 Gerdy. B 

23 Poliniere, quoted bi P 
2 * Jalade-Lafond, Deform. 

25 Humbert and Jacquier, d ' ou Symptomatiq I' 



972 CONGENITAL DISLOCATIONS. 

tion of the foetus itself might favor the displacement; and that, in some 
instances, an articular abscess, insufficient depth of the socket, with a 
laxity of the ligaments, were competent to determine the expulsion of 
the head of the femur from its natural position. 

S6dillot regards a softening and relaxation of the ligaments as the 
most frequent cause. 

Parise and Malgaigne are disposed to attribute a majority of these 
- to hydrarthrosis, or water in the joints. Says Malgaigne: "For 
myself, after having long meditated upon this subject, I have come to 
think that inflammation of the joints enjoys a grand role, both in coxo- 
femoral dislocations and in many others, and even also in various con- 
genital malformations generally ascribed to arrest of development." 
This writer admits, however, that it will not do to generalize too much 
in this matter, and that the etiology of congenital dislocations is probably 
a- complex as that of dislocations after birth. 

Dupuytren thought forced flexion of the thigh in utero would explain 
the congenital dislocations of the hip ; while Roser 1 attributes it to forced 
adduction. 

Ohaussier seems to have regarded muscular contraction, or the occur- 
rence of an intrauterine convulsion, as the cause of the example of con- 
genital dislocation of both humerus and femur seen and recorded by 
him. Since whom Guerin has greatly extended the application of this 
doctrine, having embraced in the same etiologic formula all or nearly 
all congenital dislocations. Guerin ascribes to muscular contraction in 
one form or another, and to corresponding muscular paralysis, not only 
dislocations of the femur and other long bones, but also club-foot, torti- 
collis, and various other deviations of the spine. He affirms, moreover, 
that lie has established incontestably the dependence of this abnormal 
state of the muscular system upon the absence or disappearance more or 
less complete of corresponding portions of the central nervous systems. 

Breschet and Delpech maintained similar views, especially in relation 
to the dependence of the several varieties of club-foot upon some morbid 
condition of the cerebro-spinal axis. While Carnochan remarks as fol- 
lows : " It appears most in accordance with science to refer the muscu- 
lar spasmodic retraction, upon which congenital dislocations of the head 
of the femur from the cotyloid cavity depend, to a perverted condition of 
the excito-motor apparatus of the medulla spinalis, and more especially 
of that portion of it which is in direct relation with the reflex-motor 
neirous fibres, distributed to the pelvi-femoral muscles surrounding, and 
in connection with, the ilio-femoral articulation." 

\ erneuil regards paralysis of one group of muscles as the direct cause: 
in consequence of which the normal action of the opposing muscles tends 
to displace the bone : whilst Reclus 2 applies the same theory to congeni- 
tal dislocations of the femur. In effect, therefore, both Verneuil and 
Reclus refer the abnormities in question to the nervous centres. 

Valletta ascribes these deformities solely to an original defect of the 
germ ; and Dupuytren also declares that, in the case of a congenital dis- 

1 Roeer, Arch. f. Klinik Chir., 1879. Bd. 24, Hft. 2. 
lus, Rev. Mensuelle de Chir., 1878, p. 176. 



ETIOLOGY. !<7-> 

location of the hip, the causes are coeval with the earliest organisation 
of the parts, and that the displacement is due rather to a defect in the 
depth or completeness of the acetabulum, than to accident or disease. 

Dollinger adopts essentially the same theory, attributing the imperfect 
formation and shallowness of the cotyloid cavity to an arrest of develop- 
ment, and to a premature ossification of the Y-shaped cartilage which 
unites its three portions. Grawitz, also, recognizes arrest of develop- 
ment as the essential cause, but in the seven specimens he has examined 
he has not found premature ossification of the cartilage. 

Breschet and Delpech, both of whom, as I have already stated, refer 
them to some morbid condition of the cerebro-spinal axis, imagine that 
in consequence of this morbid condition of the nervous centres, there 
exists an arrest of development in the bones, muscles, ligaments, sockets. 
and, in short, through all the apparatus of the joint which is the seat of 
the deformity. 

If we proceed to analyze these various opinions, w T e shall find that 
they are so far susceptible of classification, as that they may be arranged 
under the three following divisions : 

First, the physiological doctrines ; according to which congenital dis- 
locations are due to an original defect in the germ, or to an arrest of 
development. 

Second, the pathologic doctrines ; which refer them to some supposed 
lesion of the nervous centres, to contraction or paralysis of the muscles, 
to a laxity of the ligaments, to hydrarthrosis, or to some other diseased 
condition of the articulating apparatus. 

Third, the mechanical doctrines ; which recognize no intrauterine dis- 
locations except those which are strictly traumatic. The causes being 
understood to be the peculiar position of the foetus in utero, violent con- 
tractions or the constant pressure of the walls of the uterus, falls and 
blows upon the abdomen, and unskilful manipulation of the child in 
delivery. 

After a full and careful consideration of this subject, I am prepared 
to admit the occasional agency of all the causes enumerated, and the 
probable concurrence of two or more in many instance- ; nor do I see 
the propriety of rejecting, as Malgaigne has done, all that large class of 
malformations, which seem to depend upon an arrest of development, or 
those which appear to be due mainly or solely to intrauterine paral; 
of both of which many examples have been reported. 

As illustrating the 'relation which arrest of development sustains to 
this class of deformities, I may refer to the foots of hereditary trans- 
mission, and to the frequency with which other forms of imperfect de- 
velopment are associated with congenital dislocations. Oruveilhier 1 and 
--' have referred to examples in which the dislocations were accom- 
panied with other malformations; and Ghrawitz found this coincidence in 
examples seen by him. while Pare, Palletta, Schreger, Dupuytren, 
Robert, Bouvier, and Stromeyer have noted the marked influence 

1 Cruveilhif.-r. Trait, d'anat. path., Atlas, liv. 2.. pi. 2, fig. 28. 

. v, ___ [ :,. bot »mme individ., ' 



!»74 CONGENITAL DISLOCATIONS. 

heredity. Kronlein mentions two infants, a brother and sister, in both 
of whom there existed a congenital dislocation of one hip; and also the 
case of a boy, who was one of seven children, and whose grandmother 
presented the same malformation. 

§ 3. Congenital Dislocations of the Inferior Maxilla. 

Malgaigne affirms that u we know of no congenital dislocation of the 
jaw," and that we are "not to take seriously the pretended dislocation 
observed by Guerin upon a derencephalous infant." The example 
recorded by Robert Smith he rejects also, declaring that he does " not 
comprehend how one can see in it a dislocation." 

For myself, I know of no reason why we should not take " seriously" 
the case mentioned by Guerin, since, so far as appears in his very brief 
report of the same, it might have been a true dislocation. The specimen 
was before the Academy, and if Malgaigne, from a personal examination, 
had become satisfied that a dislocation did not exist, he ought to have so 
informed us. But since he does not speak of having made it the subject 
of special examination, I shall feel compelled to accept of it as reported 
by Guerin. 

As to the objection offered to Mr. Smith's case, namely, that "aside of 
the complete absence of its history, the subject did not present the char- 
acteristic signs of dislocation, and the dissection discovered neither maxil- 
lary condyle nor glenoid caxity," I must reply, the dissection seems to 
me to have furnished such evidence that the deformity was congenital as 
to render its history unnecessary ; the signs were characteristic, not 
indeed of a traumatic dislocation, but of a congenital dislocation, such as 
may be supposed to have been the result of an arrest of development, or 
of an original aberration of the germ. 

The following is a summary of the very complete account of this case 
given by Robert Smith : 

On the 5th of May, 1840, Edward Lacy, set. 38, an idiot from infancy, 
died at the Hardwick Hospital, in consequence of gangrene of the lungs. 
While making the autopsy, a singular deformity of the face was discov- 
ered. The right and left sides seemed as though they did not belong to 
the same individual, the left being in every respect more fully developed. 
CJpOD removing the integuments, the muscles of the right side were found 
to be much -mailer than those of the left, and especially the masseter. 
These latter having been removed also, the condition of the right temporo- 
maxillary articulation was carefully studied. 

When the mouth was closed, the external lateral ligament, instead of 
being directed backwards, was seen descending obliquely forwards, to be 
attached to a very imperfectly developed condyle situated at least one- 
quarter of an inch in front of its natural position. There was neither an 
interarticular cartilage nor cartilage of incrustation, the joint surfaces 
being invested by a thick periosteum alone; nor was there any distinct 
capsular ligament. 

Nearly the whole of the right side of the inferior maxilla was smaller 
than the left. The condyle was short and curved, being directed nearly 
horizontally inwards, and resembling much more the coracoid process 



CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 975 

than the condyle of the inferior maxilla. The coronoid process was very 
small and thin, and the sigmoid notch could scarcely be said to exist. 

The articular eminence of the temporal hone was absent, there being 
in its place nearly a flat surface destitute of cartilage ; which Burface 
presented upon its inner side a shallow and semicircular sulcus where 
the hook-like condyle of the lower jaw had played. 

The malar, superior maxillary, and sphenoid bones of the right side 
had also suffered corresponding changes of form and relative Bize. 

The motions permitted in the lower jaw were more extensive than 
those which it enjoys in its normal condition, that is, upon the right 
side the ramus could be moved very freely forwards and backwards, 
while upon the left, the condyle underwent a species of rotation upon its 
axis. During life the patient was observed to be constantly performing 
this motion, and the right side of the face was continually affected with 
spasmodic twitches. When the mouth was closed, the front teeth of the 
upper jaw projected beyond those of the lower, and when opened the 
deformity was in all respects greatly increased. 1 

Mr. Smith takes this occasion also to express his dissent from the 
views maintained by Ribes, namely, that the formation of the glenoid 
cavity is consequent upon the growth of the condyle, and that, were this 
process not formed, there would not exist either a glenoid cavity or an 
articular eminence. It is true that neither the glenoid cavity nor the 
articular eminence is found in the foetus. Until the seventh month of 
intrauterine life there exists at this point of the temporal bone only a 
plane surface, and the glenoid cavity with its corresponding eminenee is 
developed in proportion to the growth and development of the condyle. 
But Mr. Smith justly observes that although the development of the con- 
dyle does precede that of the glenoid cavity, "it by no means follows that 
the formation of the latter is due to the pressure of the former." The 
cavity, or rather the transverse eminence in front of the plane surface, 
does not exist in foetal life, because, owing to the peculiar form of the 
inferior maxilla at this period, its existence is not necessary. The ver- 
tical portion of the jaw (vertical only in the adult) is in the fetus nearly 
in the same line with the axis of the shaft, and consequently when the 
mouth is opened by the action of the muscles, the condyles are pressed 
upwards and backwards instead of upwards and forwards, as in tli" adult. 
A displacement forwards cannot therefore very well occur; and the pro- 
tection of the articular eminences is not required. As age advances the 
angles of the jaw increase, the portions upon which 'Ik- condyles real 
become more vertical, and finally a displacement forwards would occur 
whenever the mouth was well opened if the articular eminences were nol 
present to afford a sufficient protection in front. 

In the case of Lacy the foetal condition of tin- bones upon one side 
remained during life, there being neither cavity nor eminence, and tli<- 
condyle itself being only imperfectly developed; but tin- angle of the 
jaw had assumed the form which belongs to the adult, and tli<- ascending 
ramus was vertical, consequently tin- condyle became somewhat dis- 
placed forwards. 

1 Robert Smith, op. cit., p. _ 



976 



CONGENITAL DISLOCATIONS. 



Chronic rheumatic arthritis is occasionally found in the temporo-max- 
illarv articulation of old persons : and it may be important to distinguish 
it from congenital dislocation, with which, owing to the absorption of the 
articular eminence, and the consequent displacement of the condyle, it 
might possibly be confounded. 

Savs Mr. Smith : "In a majority of instances, this remarkable disease 
attacks those of advanced age, and is symmetrical; but occasionally it 
occurs during the period of adult life. In the latter case it is generally 
more rapid in its progress, is accompanied by greater pain, and is more 
liable to implicate the neck of the condyle, and the ramus of the jaw." 

When the condyle is implicated it becomes enlarged, and can be felt 
beneath the zygoma, in front of the meatus externus. The lymphatic 
glands of this region are sometimes enlarged, and the progress of the 
malady is attended with a constant but not generally severe pain. 

The deformity of the face varies according as one or both articulations 
arc affected. When the malady is confined to one joint, the chin is 
thrown slightly forwards, but chiefly to the opposite side, and when both 
are implicated, the chin is simply advanced so that the teeth project 
beyond those of the upper jaw. 

As the disease progresses, the glenoid cavity enlarges by absorption, 
and at length a considerable portion of the whole of the articular emi- 
nence disappears and the jaw becomes gradually displaced through the 
action of the external pterygoids. The disease does not extend in the 
temporal bone beyond the articulating surface of the glenoid cavity. 
The condyle assumes a variety of forms, sometimes being greatly en- 
larged in all its diameters, while its upper surface may be flattened, or 
conical. The articular cartilage disappears; but Mr. Smith has never 
yet found any foreign bodies in the joint, and in only one instance have 
the surfaces been polished or eburnated as we often see in examples of 
chronic rheumatic arthritis occurring in the hip, knee, and other joints. 

The following is an excellent summary of the diagnostic marks be- 
tween congenital, accidental, and rheumatic dislocations, given by this 
writer: 

"1. In the congenital dislocation, the mouth can be freely opened and 
closed; in chronic rheumatism these motions can be performed, but 
Dot without uneasiness to the patient, an uneasiness which sometimes 
amounts to severe pain ; in dislocations from accident, the mouth cannot 
be closed. 

"2. An involuntary flow of saliva accompanies the accidental disloca- 
tion alone, although in some cases of chronic rheumatism there is an 
increased secretion of that fluid. 

"3. In congenita] dislocation, the teeth of the upper jaw project be- 
yond those of the lower; the reverse is observed in accidental dislocation 
and in chronic rheumatism. 

•■4. In congenital dislocation there is no fulness in the cheek, such as 
the coronoid process produces in cases of accidental dislocation, and 
the condyle is not enlarged, as in some instances of chronic rheumatic 
arthritis." 1 



R. Smith, op. cit., p. 292. 



CONGENITAL DISLOCATIONS OF PELVIC BONES. 977 



§ 4. Congenital Dislocations of the Spine. 

Says Guerin of the subluxation occipito-atloidean there are two 
varieties: "First. Backwards, consisting in an exaggerated flexion of 
the head upon the front of the neck and chest, with a commencement of 

sliding backwards of the occipital condyles upon the articular facets of 
the atlas. Here are two examples in foetal anencephalous monsters. 

Second. Forwards. Those who follow my consultations can recollect 
having seen last year an infant, about two or three months old, who 
offered a remarkable example. The head was exactly applied against 
the posterior part of the neck, and upper part of the back. There was 
probably a sliding of the condyles forwards, with elongation of the ante- 
rior ligaments." 1 

The existence of the first of these varieties has since been denied by 
Guerin himself: 2 and it will be noticed that he only speaks of the second 
as a probable subluxation forwards. Neither of them can therefore be 
regarded as established. 

Guerin further remarks that he has observed subluxations in the other 
regions of the spinal column many times ; and he showed to the Academy 
a foetus in which the spine presented, besides the occipito-atloidean dis- 
placement, a series of angular flexions in the antero-postcrior direction, 
with sliding of the articular surfaces. 

In attempting to appreciate the value of Guerin's observations upon 
this point, it must be remembered that he regards all cases of congenital 
torticollis, and other deviations of the spine, as examples of subluxation; 
and, in some sense, I think the theory of this distinguished surgeon 
may be regarded as correct. The amount of articular displacement 
between each of the adjacent vertebrae may be very inconsiderable in 
any such case. yet. however trivial, if it exceeds the limits of natural 
motion, it may properly enough be regarded as the commencement of s 
dislocation. 

§ 5. Congenital Dislocations of the Pelvic Bones. 

Bas.-iu< speaks of a diastasis or separation of the sacro-iliac symphy- 
sis, observed by him in newly born children, and infant.-: but, accord- 
ing to Malgaigne, his account of these cases is not such a- to warrant 
any conclusions as to the true nature of the displacements. 

</<>ngenital exstrophy of* the bladder is accompanied always with a 
deficiency of the centra] and upper portion- of the pubic bones, the 
result manifestly of an arresl of development ; but these cases, of which 
I have Been several examples, are not properly examples of congenital dis- 
locations, but only of diastases, the separated portions remaining in their 
normal position with reference to each other, excepl that thej are not 
prolonged sufficiently to meet in the median line. 

Guerin declare-, however, that he ha- seen congenital displacement, 
or overriding of the iliac bone npon the sacrum, accompanied with coxo- 
femoral dislocation and curvature of the -pine. The same writer men 

1 Guerin. op. cit., 1811. 



978 CONGENITAL DISLOCATIONS. 

tiona :ni example, in a foetal monster, of diastasis of the pubic bones, and 
of the sacro-iliac symphysis, accompanied with a turning out of the pubes 
upon the external face of the ischium. 1 

§ 6. Congenital Dislocations of the Sternum. 

Seger alone has reported one example of dislocation of the xiphoid 
cartilage from the sternum. 

A woman in the fifth month of pregnancy fell and dislocated her 
shoulder. Just four months after this she was brought to bed with an 
infant, well formed, except that, soon after it was born, the ensiform car- 
tilage was observed to be remarkably movable, especially when the child 
hiccoughed, to which it was very subject. The cartilage was separated 
from the sternum by the breadth of the little finger. No treatment was 
employed ; the cartilage gradually became restored to its place, and in 
about one year it was firmly united to the sternum. 2 

§ 7. Congenital Dislocations of the Clavicle. 

Malgaigne says that a congenital dislocation at the sterno-clavicular 
articulation has never been observed ; but Guerin declares that he has 
established the existence of three varieties, namely : 

1. A dislocation of the sternal end of the clavicle inwards and forwards ; 
this extremity of the clavicle lying in front of the sternal fourchette. In 
illustration of which he presented to the Academy a plaster cast of a girl 
eight years old, in whom the displacement existed upon both sides. 

2. Inwards and upwards. Observed by him in a girl eight years old; 
but w T hich displacement took place only when the arm was moved, and 
through the contraction of the sterno-cleido-mastoideus muscle. 

3. Backwards. Of which he presented two examples in the corre- 
sponding sides of a foetal monster. 

Shaw 3 reports a case of congenital dislocation of the sternal end of the 
clavicle upwards in a girl two and a half years old. 

I believe I have already referred to Fergusson's case of dislocation of 
the sternal end of the clavicle forwards, which occurred during birth. 
The end rested in front of the sternum, and could be pushed into its 
place with great ease; but when left alone it immediately slipped out 
again. Nothing was done ; a new joint formed, and the child afterwards 
possessed as much power in the one arm as in the other. 4 

Nadaud 6 also met with a dislocation of the sternal end forwards in a 
newly born child which had been delivered rapidly by the breech. The 
arm was immobilized by a sling, and the cure took place without de- 
formity. 

Ghierin says that he has seen a dislocation upwards and outwards at 



Ghi6rin, Gaz. Mod., 1851, p. 227. 
' n. Nat. Curios., 1677. 

Fork Med. Record, Aug. 18; Virchow und Hirsh's Jahresbericht 



Ephem. Nat. Curios., 1677, from Malg., op. cit., p. 410. 
Shaw, New V ' 
fur 1877, p. 338. 

Fergusson, System of Surg., 4th Amer. ed., 1853, p. 203 
Nadaud, Bordeaux Medical, 1874, No. 42. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 979 

the acromial end of the clavicle in a foetus of three months. And I 

have mentioned, in the chapter on Traumatic Dislocations of the Bones, 
one case seen by me at the end of the fourth week of life. 

In regard to the treatment of either of these displacements of the 

clavicle, I need only remark that a reduction ought to be attempted; 
and. if practicable, without much confinement to the little patient, it 
should he maintained until the bones have become fixed in their natural 
positions. It is quite probable that this can never be accomplished, at 
least perfectly; but it will nevertheless be proper always to make tin' 
attempt. 

§ 8. Congenital Dislocations of the Shoulder. (Upper End of the 
Humerus. ) 

Guerin affirms that he has established the existence of three varieties 
of congenital scapulo-humeral dislocations, namely : 

1. Dislocations of the head of the humerus downwards; of which 
variety he presented to the Academy a plaster cast taken from a boy 
ten years old. The displacement existed in both arms, but much more 
pronounced in the right than in the left arm. It was due wholly to 
paralysis of the muscles about the joint, and to elongation of the capsule. 

2. Downwards and inwards ; complete upon one side and incomplete 
upon the other, in the same person. The head of each humerus was 
applied against the ribs, and the arms maintained in an abduction almost 
horizontal, under the influence of the retraction of the deltoid muscles. 
•' The same case," Guerin remarks, "has been confirmed by Roux." 

3. Subluxation upwards and outwards; seen on both sides in a foetal 
monster, which was offered to the Academy for examination : and in one 
arm of a young man fifteen years old, of which Guerin presented a plaster 
cast. " It is characterized by a sliding of the head of the humerus in 
the direction indicated; this sliding being favored by a corresponding 
displacement of the coracoid and acromion processes.' 

Malgaigne, who regards "all luxation- in consequence of paralysis as 
itially posterior to birth."" will not admit the first example mentioned 
by Guerin : but. as I stated before, the objection- made by Malgaigne 
have failed to convince me of* the propriety of rejecting all of this class 
of reported examples. Of th<- second case, mentioned by GueVin as 
having been confirmed by Roux, Malgaigne declares thai he has consulted 
Roux upon this matte]-, and that he affirms thai " he hag never seen a 
congenita] luxation of the shoulder." 

Robert Smith has met with but twoofthe forms of congenital disloca- 
tion of the humerus described by Guerin, namely, that in which the 
head of the humerus is displaced forwards, and that in which it is dis- 
placed backwards. Of the first variety he hac era! examples. 

The first was in the person of Alexander Steele, set. 29, who presented 
both a dislocation of the head of the humerus under tie- coracoid pro- 
of the left scapula, and pes equinus in the foot of the left leg. The 
muscles of the arm and Bhoulder upon thai Bide were feeble and gr< 

1 ^u'lin. '.).. <it.. |'. -'Ji. 



CONGENITAL DISLOCATIONS. 

atrophied. The humerus was shortened; its head being of the natural 
size and form, but when the arm hung by the side it dropped so far from 
ckel as to permit the thumb to be placed between the head and the 
acromion process. By pressing the humerus forwards, the finger could 
be placed in the outer part of the glenoid cavity ; and although the head 
could be moved about thus freely, it seemed naturally to occupy only the 
anterior half of the glenoid fossa. 

Robert Smith's second example of subcoracoid congenital dislocation 
was presented in the person of Mr. H., aet. 20, the condition of whose 
left shoulder resembled almost precisely that of Mr. Steele. "The de- 
formity had existed from his birth, but became much more obvious and 
striking as he increased in age and stature." 

In the third example the child had attained nearly the age of one year 
before the condition of the limb attracted attention, which was then ex- 
cited, not by the deformity of the shoulder, but by the atrophied condi- 
tion of the muscles of the arm. The child had never complained of pain 
about the joint, nor had he ever met with any accident. ' No doubt this 
also was an example of paralysis, and it is not improbable that it w r as 
congenital, but the evidence upon this point is not very conclusive. 
AVI i en seen by Mr. Smith, he w T as nine years old, the shoulder and arm 
presenting the same appearance as in the other cases mentioned. 

The fourth was also subcoracoid and symmetrical, the same deformity 
existing in both shoulders. This was in the person of a female, aet. 21, 
who had been for many years a patient in a lunatic asylum, and who 
died of chronic inflammation of the meninges of the brain. 

Mr. Smith, who himself made the autopsy, first noticed the condition 
of the left shoulder. The muscles were atrophied ; the head of the hu- 
merus could be felt lying under the coracoid process; the elbow projected 
from the side, but could be readily brought into contact with it. The 
right shoulder presented the same appearance, but the deformity was 
somewhat less, and the head of the humerus was not so directly under- 
neath the coracoid process. 

From the external appearances presented by the two shoulders, Mr. 
Smith did not doubt that these deviations from the natural state of the 
parts were not the result of violence. 

Proceeding to remove the soft parts upon the left side, scarcely any 
trace was found of a glenoid cavity in its natural situation, but imme- 
diately underneath the coracoid process, upon the costal surface of the 
scapula, was formed an oblong socket completely surrounded by a cap- 
sular Ligament, which ligament included also that small portion of the 
original socket which remained. The head of the humerus was changed 
in form, being oval, and fitted, in some measure, to both the old and new 
sockets, upon which it seemed to rest alternately. 

Upon tin- right side, although the condition of the bones was some- 
what different, the characteristic features of the deformity were similar. 

Malgaigne, who quotes Mr. Smith as saying that these dislocations 

must have been congenital, and for no other reason than because they 

symmetrical, has scarcely done this author justice. Says Mr. 

Smith: " The position of the glenoid cavity, the remarkable form of the 

head of the humerus, the presence of a perfect glenoid ligament, the ab- 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 981 

sence of any trace of disease, and the existence of the deformity upon 
each side, all indicate the original nature of the malformation." 

The only example of backward dislocation seen by Mr. Smith was also 
symmetrical, and seems to be equally well authenticated. This was in 
the person of a woman named Doyle. ;et. 42, a lunatic also, who died 
February 8, 1839, in Dublin. She had been a patient in the lunatic 
asylum fifteen years, and was subject to severe epileptic convulsions, 
which ultimately proved fatal. 

Mr. Smith made the autopsy on the day following her death. The 
convolutions of the brain were small and atrophied, as is frequently 
observed in idiots. 

The two shoulders resembled each other so perfectly, both in external 
appearance and in their anatomy, that Mr. Smith has only found it 
necessary to describe particularly the condition of one. 

The coracoid process was remarkably prominent, but the acromion 
was not so prominent as in accidental dislocations of the shoulder. 
The head of the humerus could be seen and felt distinctly moving with 
the shaft, upon the dorsal surface of the scapula. On removing the 
integuments, muscles, etc., no trace of a glenoid cavity was found in its 
natural situation ; but upon the external surface of the neck of the 
scapula was a well-formed socket, which received the head of the humerus. 
This socket was covered with a cartilage of incrustation, and surrounded 
by a perfect capsule. The tendon of the biceps arose from the top and 
internal margin of the socket. The form of the acromion process was 
changed: the capsule smaller than natural: the head of the humerus 
irregularly oval, its anterior half alone being in contact with the glenoid 
cavity: the great tubercle natural, but the lesser was elongated and 
curved, forming a process of an inch in length, around the base of which 
the tendon of the bicep muscles played. 1 

Gaillard 2 relates the case of a female child whose left arm was dis- 
covered to be deformed a few days after birth, and the elbow separated 
from the side. Later, the arm was found to be nearly immovable, and 
only at the end of four years was the dislocation recognized; but no 
attempt at reduction was then made. When sixteen year- old, -ho was 
by Gaillard. who found the head of* the humerus in the infra- 
spinous fossa. The scapula, clavicle, and arm were preternaturally small ; 
the forearm, although well developed, could doI be completely extended 
nor supinated. 

Despite these unfavorable circumstances, Gaillard determined to make 
an attempt to accomplish the reduction. Four times in the space of eight 
days he submitted the arms to extension made :) t right angles with the 
body, by means of sixteen-pound weights, the extension being continued 
from twenty to twenty-five minutes, and occasionally his own exertions 
_ added to the weights. On the fourth attempt, the bead of the 

bone was drawn gradually forward-, and by a rotary motion if 

finally made to dip into its socket; but became immediately displaced. 
The next day Gaillard reduced it anew, aid retained it in place one hour. 

1 Robert Smith, 

M 



982 CONGENITAL DISLOCATIONS. 

Six dnvs later it -was again reduced, and, by the aid of bandages, per- 
manently retained in place. The slight pain and swelling which followed 
soon disappeared : and, by the aid of careful exercise, at the end of two 
vears tlie arm had increased in length, and the patient could use the arm 
and hand so much better than before, as to encourage a hope that the 
recovery would be complete. 

Aristido Rodrigue, of Holidaysburg, Penn., in a letter to the editor of 
the American Journal of the Medical Sciences, gives the following brief 
account of a case of intrauterine dislocation of the shoulder, compli- 
cated with a fracture of the forearm: 

"The woman, when about four months gone with child, fell on her 
Kit side, striking a board, and felt herself much hurt at the time; at 
the full period she was delivered of a full-grown large boy with the fol- 
lowing deformity : dislocation of the humerus into the axilla; fracture 
of both bones of the forearm of left side, lower third. Dislocation could 
not be reduced ; union of the bones of the forearm by ossific matter com- 
plete; bones passing each other, and hand at an angle of about 40°; 
the child did well otherwise; now, four years old, strong and healthy; 
humerus has grown nearly apace with the other; forearm has not, and 
remains short and deformed as at birth; the hand is of the same size 
with that of the sound side." 1 

I was asked to examine the arm of Joseph Heins, set. 7, May 12, 
1878, who had a subspinous dislocation of the left humerus. The parents 
Stated that the birth of the child was premature, and that he was de- 
li vered with forceps, and as a head presentation. On the following day 
a swelling was noticed over the shoulder. On examination I found the 
head of the humerus resting upon the dorsum of the scapula below the 
spine. The scapula is smaller than the opposite scapula, and the arm is 
one and a half inches shorter than the other. The coracoid process is 
very prominent, and the humerus somewhat rotated inwards. He uses 
the arm nearly as well as the other, and in this respect it is yearly im- 
proving. 

It is difficult to say positively whether this was strictly a congenital 
displacement, or whether it was caused by some violence employed in the 
act <>f delivery. 

Jenni 2 has recorded an example of congenital dislocation into the 
axilla of the left arm in a girl six years old. The child at birth occu- 
pied a position across the pelvis, demanding the intervention of the 
accoucheur. From the time of birth the arm hung inert beside the 
body. Both the left arm and forearm were somewhat smaller in diameter 
and shorter than the same portions of the right. Jenni reduced the dis- 
location ton times in succession, but it was as often reproduced. He 
then applied a plaster dressing and left it on fifteen weeks, when he sub- 
stituted a roller bandage, which was permitted to remain some time, after 
which the dislocation was not reproduced. 

Kiister, 8 in ;i case of* double congenital dislocation seen in a child one 
year old, and whose arms were seriously maimed in consequence, pro- 

drigue, loc. cit., Jan. 1864, p. 272. 
-' Jenni. Corresp. Blatt fur Schweiz. Aerzte, ISTo. 19, p. 580, ler, Oct. 1879. 
■ Kuster, Berliner Klin. Woehenschrift, No. 1, p. 9, 6 janv. 1879. 



CONGENITAL DISLOCATIONS OF HEAD OF RADIUS. 988 

posed to open the articulation and restore the bone to place. We are 

not informed whether he carried his intention into effect. 

§ 9. Congenital Dislocations of the Radius and Ulna Backwards. 

It is not uncommon to meet with examples of a slight subluxation 

backwards of these bones in feeble and newly born infants: which con- 
dition is probably due to a relaxation and elongation of the capsule. It 
is characterized by a preternatural mobility of the joint, and especially 
by the circumstance that the limb is capable of abnormal extension, or 
flexion backwards, as it is sometimes called. Gruerin lias seen this ren- 
dition more advanced, the bones of the forearm having actually overlapped 
somewhat upon the lower end of the humerus, so that the articular 
surface of this latter presented itself in the fold of the elbow. This was 
especially observed in a girl of fourteen and a boy of thirteen years, and 
also in the two arms of a foetal monster. 1 

Chaussier relates that a young woman, at the commencement of the 
ninth month of pregnancy, perceived suddenly movements of the fetus 
so violent that she almost lost her consciousness. These movements wore 
repeated three times in the space of six minutes, after which everything 
returned to its natural order, and the accouchement took place naturally 
and at the usual term. The infant was pale and feeble, and presented a 
complete backward dislocation of the radius and ulna. 2 

§ 10. Congenital Dislocations of the Head of the Radius. 

Examples of this dislocation have been reported by Dupuytren, Cru- 
veilhier, Sandiforte, Adams. Dubois. Ycrneuil, Deville. Robert Smith, 
Guerin, and Hayem, most of which were in the direction backwards, 
Bome outwards, but only one of them forwards; some were double, the 
same deformity being presented in both arms, ami others were single. 
In a few examples the dislocations were complicated with a consolidation 
of the radius to the ulna, and in others with a deficiency of the ulna or 
with some deformity indicating its congenital origin. 

Of the symmetrical or double dislocation backwards Dupuytren fur- 
nishes the following example, presented to him in L830, by M. Loir: 

••The abnormal position which the head of either radius had assumed 
was at the hack part of the lower extremity of the humerus, beyond 
which it extended for the space of al least an inch. This disposition of 
parts was absolutely identical on the two sides, and had all the chara 
of a congenital affection." 8 

In January, 1866, John Fitzmorris, aet. 19, was admitted to the Bel- 
levue Hospital, laboring under a general scrofulous cachexy, in whose 
person I found ;> congenita] dislocation of the heads of botn radii, out- 
wards. The dislocations are complete. The ulna are in place and of 
natural form, hut their articulations at the wrist are loose. Tie- same 
remark applies to all other joints in the body. The power of pronation 

' lhauasier, fro ' 

1 17. 



! 98 I CONGENITAL DISLOCATIONS. 

and supination is unimpaired, as well, also, as the power of flexion and 
extension. 

In the example of outward dislocation mentioned by Deville, there 
was an almost complete absence of the ulna, the head of the radius 
mounting upwards more than three centimetres above the level of the 
articulation. 1 

Guerin, who has described an example of a forward dislocation, says it 
was observed by him in a girl of seven years, and that it was symme- 
trical. The two radii lay in front of the humeri, near the coronary 
fossettes. 2 Hayenr 8 has also reported an example of double forward 
dislocation, which he believed to be congenital. 

§ 11. Congenital Dislocations of the Wrist. 

Guerin thinks he has seen three forms of congenital dislocation of the 
wrist. First, a dislocation forwards, characterized by a sliding of the 
wrist before the bones of the forearm, and by the projection posteriorly 
of the lower ends of the radius and ulna ; seen in an infant of six 
months, and in two adults. Second, backwards and upwards; seen 
in a child of six years, and accompanied with an incomplete paralysis 
of all the muscles of the forearm and hand. Third, backwards and 
outwards : in a girl of fourteen years, accompanied with incomplete 
paralysis. 4 

Guerin has also seen three examples of dislocation outwards in foetal 
monsters, and one of dislocation inwards, as the result of arrest of 
development. 

Robert Smith believes that the case of simple dislocation of the wrist 
or of the carpus forwards, mentioned by Cruveilhier in his Anatomie 
Pathohgique, was an example of congenital dislocation; and he relates 
two other cases equally remarkable which came under his own observa- 
tion. One was in the person of Deborah O'Neil, a lunatic and epileptic, 
who died when thirty-six years old. Both upper extremities were de- 
formed from birth; the right presenting an example of dislocation of 
the carpus forwards, and the left of dislocation of the carpus backwards. 
Tin- dissection showed that there had been an arrest of development, 
especially in the bones of the forearm and carpus. The second was in 
the person of a young woman who died of phthisis in the Richmond 
Hospital; the right wrist presenting an example of congenital disloca- 
tion of the carpus forwards from arrest of development also. 5 

Marrigues describes a very singular congenital displacement which he 
found upon a newly born infant. The radius and ulna were widely sepa- 
rated below, and in the interspace was lodged the whole of the first range 
of the carpal bones; the hand being strongly turned inwards. 6 

1 Deville, Bulletin de la Soc. Anat., 1849, p. 153. 
'-' Gu6rin, op. cit., p. 31. 

Bay em, Bull. Soc Anat. de Paris, 1864, p. 56. 
4 Guerin, p. 717. 6 R. Smith, op. cit., pp. 238, 251. 

,; Marrigues, Malgaigne, from Journ. de Med., t. ii. p. 31, 1775. 



CONGENITAL DISLOCATIONS OF THE HIP. 985 

§ 12. Congenital Dislocations of the Fingers. 

Chaussier found in a foetus the last three fingers of the left hand dis- 
located at the metacarpophalangeal articulation. The thighs, knees, and 

feet were also dislocated. 1 

A. Berard speaks of an incurvation backwards o\' the last two pha- 
langes of the fingers as having been occasionally seen in newly horn 
children of the female sex : and Malgaigne adds that he has himself Been 
a woman who had. from birth, all the phalangette carried backwards to 
an angle of 135°. leaving the heads of the phalanges projecting forwards 
under the skin. 2 

Robert has seen, in a girl six years old, a congenital lateral dislocation 
of the phalangette of the index finger, which was inclined outwards at 
an obtuse angle. The external condyle of the lower extremity of the 
proximal phalanx was slightly atrophied, and the internal presented a 
corresponding projection. Robert cut the internal lateral ligament by a 
subcutaneous incision, but without any favorable result. 3 

§ 13. Congenital Dislocations of the Hip. 

Dupuytren thought that double dislocations of the hip-joint, as con- 
genital accidents, were more common than single dislocations, but in the 
experience of Pravaz the rule has been reversed, he having met with but 
four double dislocations in a total of nineteen. 

They have been noticed much often er in females than in males. Of 
forty-five examples mentioned by Dupuytren and Pravaz, only seven or 
eight were males. 

The following table, constructed by Poinspt from statistics gathered 
by Drachmann, Pravaz, and Kronlein, respectively, ought to be accepted 
as conclusive evidence that unilateral dislocations are more frequent than 
bilateral, and that these deformities are much more frequent in females 
than in males: while as regards its occurrence in the right or left limb, 
no marked preference exists for either. 





Limits <i( 

.bservation. 


Malei 


i. Females. 


Unilateral. 




itions. 




Right 






A. <r. Drachmann 77 . . 

Pravaz 107 

Kronlein 90 




10 

11 

1 » 


96 
76 


24 

•J7 


24 


5 


51 
81 






35 289 


88 


7.', 


5 








274 




168 




111 



Congenital dislocations of the femur may be complete or incomplete. 
Of T ] . us, four rarietie* Q noticed. 

i f ! ussier, M ■ _ . t ii. p. 751. 



CONGENITAL DISLOCATIONS. 

Upwards and backwards, upon the dorsum ilii. This variety is by far 
the most common. 

Upwards and forwards ; the head of the femur resting upon the emi- 
nentia ilio-pectinea. 

Downwards and forwards into the foramen thyroideum ; of which 
variety Chaussier alone mentions one example ; but Delpech found in an 
infant, born paralytic, the head of the femur lodged habitually near the 
foramen thyroideum. 

Directly upwards ; seen by Guerin, Pravaz, and others ; the head of 
the femur being placed immediately without the anterior inferior spinous 
process of the ilium. 

Guerin has observed, moreover, a single variety of subluxation ; char- 
acterized by the incomplete displacement of the head of the femur in the 
direction upwards and backwards, so that it rested upon the edge of the 
cotyloid cavity : " observed often in newly born children, and with those 
in whom the muscular dislocations are effected spontaneously after 
birth." 

Through the courtesy of Dr. Davis, of this city, I was permitted, in 
March, 1865, to see a child, the daughter of a gentleman residing in 
Victor, Monroe Co., N. Y., who was born in 1860, with dislocation of 
both knees and both hip-joints. The legs at the time of birth were 
doubled forwards upon the thighs, the heads of the tibias resting upon 
the front of the femurs, one inch above the condyles, the thighs being at 
right angles with the body and the feet touching the abdomen. The 
knees were drawn closely together. The dislocation of the heads of the 
femurs was not at this time recognized. By constant pressure Dr. J. B. 
Palmer had succeeded, at the end of one year, in restoring the legs to 
position, the thighs remaining flexed ; but when two years old she began 
to walk, with her body bent forwards. The displacement of the hip- 
bones was then first discovered. When four years old the sartorius and 
tensor vaginae femoris were severed, but with very little benefit. At the 
time of my examination she was five years old. The thighs w T ere still 
flexed and adducted; by pressure upon the knees the femurs could be 
slid upwards and backwards upon the ilium one inch ; on rotating the 
fen hi is the trochanters were observed to move upon a very short radius, 
indicating the entire absence of head and neck. She walked with the 
gait peculiar to these conditions. 

Both I telpech and Guerin have called attention to two varieties of what 
the latter terms pseudo-luxations ; of which the first simulates a disloca- 
tion upwards and backwards, and the second a dislocation downwards and 
forwards. In these examples, the extreme adduction or abduction of the 
thighs might lead to a belief that the bones were dislocated, when in fact 
the abnormal position of the limbs is due only to muscular contraction, 
without actual articular displacement. 

In the remarks which follow I shall have special reference to that 
form of congenita] dislocations of the femur in which the head of the bone 
pests upon the dorsum ilii, as being that which will be presented ina vast 
majority of cases, and which, characterized by the same general pheno- 
mena, may be regarded as typical of all the others. 

Somatology. — First. When the dislocation is double. 



CONGENITAL DISLOCATIONS OF THE HIT. 987 

In these examples the deformity is often found to be absolutely sym- 
metrical; the opposite limbs being of precisely the same length, and in 
the same relative positions : a circumstance which, when it exists, may 
render the diagnosis more difficult, or may cause it to be for a long time 
entirely overlooked. It is in such eases especially that the deformity is 
not usually discovered until the child begins to walk. 

The first circumstance which would naturally arrest our attention, if 
the person who is the subject of this double dislocation is stripped and 
placed erect before us, is the great apparent length of the arms and of 
the body in comparison with the lower extremities. We may next ob- 
serve that the great trochanters are carried upwards and backward-, bo 
as to make a remakable projection in this direction; the lumbal- portion 
of the spinal column is thrown very much forwards and the dorsal portion 
backwards. The thighs incline inwards, so as almost to cross each other : 
the whole of the lower extremities are imperfectly developed and feeble; 
the toes are generally pointed directly forwards, or they may be noticed 
to turn inwards. 

When the person stands, and his limbs are not in motion, the heel is 
usually brought down fairly to the floor; but in walking, and especially 
in the attempt to run, he touches only the balls and toes of bis feet. 
" When they are about to walk." says Pravaz, ,k we see them lift them- 
selves upon the points of the feet, to incline the superior pun of the trunk 
toward the member which is about to support the weight of the body, and 
to lift the other from the ground with an effort, in order to carry it for- 
wards. At this moment one of the trochanters, that which corresponds 
to the column of sustentation, appears to approach the iliac crest more 
nearly than when the patient is standing upon his two feet." In conse- 
quence of which mobility of the thigh-bones, the patient assumes a pe- 
culiar waddling gait, which is not only ungraceful, but exceedingly 
fatiguing. 

The difficulty of progression is, however, very variable in different 
persons. Sometimes the patient requires no aid whatever, and at other 
times he cannot walk without assistance. Generally it increases with 
age. It is especially deserving of notice that in rapid progression the 
mobility of the heads of the femurs i- appreciably less than in sIoti 
progression, which is explained by the more constant and vigorous con- 
traction of the muscles about the joint, when the motion- of tin- limb 
nre rapid. 

In the recumbent posture, the thighs may be drawn down easirj to 
almost their natural positions. Tie- only exception to this rule, accord- 
ing to Carnochan, "is when the head of the femur has escaped from the 
natural capsule in which it was originally inclosed, and a I has 

been formed upon the dorsum of the ilium. 

Abduction is performed with difficulty; adduction and rotation, espe- 
cially inward-, being less restricted. 

- scond. Wlieu the dislo< only upon one side. 

In these cases the symptoms are essentially the same as in the double 
dislocation; with only" such Blight differences and peculiarities ="- would 
naturally suggest themselves T " tin- surgeon, and which will not. there- 
fore, demand from me a special consideration. 



CONGENITAL DISLOCATIONS. 

Pathology* — The head of the femur is sometimes merely changed in 
form and consistence, the neck also undergoing corresponding alterations 
in its size, form, direction, etc.; at other times the head is absent alto- 
gether, and with it a considerable portion of the whole of the neck has 
disappeared. 

The pelvic bones are usually more or less deformed. The acetabulum 
may be entirely deficient, or it may present itself as an irregular bony 
protuberance, without cartilage, fibro-cartilage, or ligaments. Some- 
time it exists as an oval or triangular cavity, which is expanded at its 
superior and posterior margin into a distinct fossa, where the head of the 
femur, descending from the dorsum ilii, occasionally rests. A new cavity 
is formed usually upon the side of the pelvis, which is shallow and with- 
out an elevated margin, or it may be deeper, and more complete in its 
construction by the addition of an osseous border. In either case, the 
new socket is often lined with a true periosteum and synovial membrane; 
hut not unfrequently it is unprotected by any soft tissue, the surface being 
hard and polished like ivory. 

The head of the femur, having escaped from its original capsule, 
through a button -like opening, rests in this socket constantly. In still 
other examples the head of the femur remains within its capsule, and may 
be observed to play backwards and forwards between the two sockets ; 
or the head and neck being absorbed, and the capsule remaining entire, 
the latter is converted into a long narrow sac, somewhat contracted in 
its centre ; or finally into a firm ligamentous cord, which being attached 
to the stunted upper extremity of the femur, limits its motions in the 
direction of the crest of the ilium. In this case no new socket is formed. 

A portion of the pelvi-femoral muscles are contracted, in consequence 
of an approximation of their points of origin and insertion, and remain- 
ing in a state of comparative, if not absolute, inertia, they become atro- 
phied, or pass into a condition of fatty degeneration ; while other muscles, 
in cnn-e<juence of the increased labor which they have to perform, become 
hypertrophied, or degenerate into a fibrous tissue. 

Treatment. — Says Dupuytren; "Of what possible utility can it be to 
practise extension of the lower extremities in these cases, even supposing 
the limbs could be thus brought to their natural length ? Is it not evi- 
dent that the head of the femur, finding no cavity fitted to receive and 
hold it. would, when abandoned to itself, resume its former abnormal 
position ".' There is something more rational and feasible in adopting a 
palliative course of treatment. When we call to mind the natural prone- 
oess which the heads of thigh-bones have to ascend to the external iliac 
fossae, and that this tendency is partly due to the superincumbent weight 
of the body, and in part to muscular action, a just conception may be 
formed of the indications on which the employment of palliative reme- 
dies should be founded. The object should be to relieve, the lower limbs 
<»f the superincumbent weight on the one hand, and on the other to 
moderate the muscular action. Both of these indications are in part 
fulfilled by repose: and the attitude most conducive to this effect is the 
sitting posture, in which the weight of the upper part of the body is not 
transmitted to the lower extremities, but is centred in the tuberosities of 
tli.- ischia. Therefore, laboring persons afflicted with this infirmity should 



CONGENITAL DISLOCATIONS or THE HIP. 989 

be recommended to adopt a sedentary occupation, as a calling which re- 
quires much standing and walking about would dangerously aggravate 
their deformity. Yet one would scarcely be willing to condemn BUch 
individuals to perpetual repose; and to avoid this it is necessary to dis- 
cover some means for diminishing the inconveniences which attend the 
upright posture, the act of walking and other exercises. Experience 
has taught me hitherto but two methods of obtaining this important ob- 
ject: the first consists in the daily employment of a perfectly cold bath, 
in which all the body should be immersed for the space of three or four 
minutes, the head being protected by an oiled-silk cap: the water may 
be fresh or salt : and the only precautions necessary to take are to avoid 
bathing when the body is in a state of perspiration, or when the cam- 
menial discharge is present. These baths have a local, as well a- general. 
tonic effect. The second method consists in the constant use. at leasl 
during the day, of a belt, which embraces the pelvis, fitting closely over 
the great trochanters, and keeping them at a constant height. .-<> ;i- to 
bind the parts together, and prevent that continual unsteadiness of the 
body which results from the loose connections of the head- of the thigh- 
bones. For the proper fulfilment of these indications, certain precau- 
tions are necessary in the construction of this cincture: m the first 
place, it should occupy the narrow interval between the crest of the ilium 
and great trochanters, completely filling this space, and therefore being 
about three or four fingers' breadth, according to the age and size of the 
patient. It should further be well padded with wool or cotton, and cov- 
ered with doeskin, so that it may not abrade the parts to which it is 
applied : and there should be a piece let in on either side, so ;i- to receive 
and support the trochanters without entirely covering them ; it should be 
buckled behind, and padded straps be carried under the thigh, and across 
the tuberosity of the ischium, on either side, to prevent the /"tie from 
slipping up. I do not mean to assert that I have ever succeeded in com- 
pletely getting rid of the inconveniences of congenital dislocations of the 
thigh-bones, but I have prevented their increasing, and have rendered 
supportable what I could not cure. The testimony of some patient- t<» 
the value of this treatment ha- been of ;> most unequivocal character; 
for being worried by the pressure of the belt, they have laid it aside, but 
have speedily restored it again, ;is they found that without it they had 
neither a sense of firmness in the hip. nor confidence in walking. 

In relation to which opinion- the same excellent writer subsequently 
made the following candid admission : " I at first thought that no benefit 
would be derived in the-'' cases from the employment of continual trac- 
tion on the lower extremities, for reasons already Btated ; but the experi- 
ments of MM. Lafond and Duval tend to throw some doubt on the 
correctness of this conclusion. These distinguished practitioners U 
the influence of extension, in their orthopaedic institution^ ;■ child eight 
or nine years of age, who was the subject of double congenital disloca- 
tion of the hip ; after the uninterrupted employment of this treatment 
f,,r .Mine weeks, 1 satisfied myself that the limbs had resumed then- 
natural length and direction; but I was not ;■ little astonished t<> find 
that, after extension had been persisted in for three or four month- con- 
tinuously, the greater part of the beneficial results remained for several 



990 



CONGENITAL DISLOCATIONS. 



weeks undiminished. It would be idle, it is true, to generalize on this 
single case; but as an isolated example of the utility of extension it is 
interesting, and it may be the forerunner of more important results." l 

Since which time Humbert and Jacquier, who, as well as Duval and 
Lafond, confined themselves to the treatment of deformities, claim to 
have met with equal success in the management of these cases by exten- 
sion alone; and, still more lately, Guerin, of Paris, and Pravaz, of 
Lyons, by the adoption of the same general principle more or less modi- 
fied, have added new triumphs, and greatly enlarged its application. 

The means recommended and practised by Guerin are : first, pre- 
paratory extension destined to elongate the muscles as much as possible; 
-ccond, subcutaneous section of the muscles which mechanical extension 
lias not sufficiently elongated ; third, extension of the ligaments, and 
even, if extension does not suffice, their subcutaneous section ; fourth, 
manoeuvres destined to effect reduction ; fifth, treatment designed to con- 
solidate the reduction, and consisting in the application of the apparatus 
proper to maintain the extension and separation of the divided tissues, 
and to retain the head of the femur in its place ; finally, in the gradual 
execution of movements proper to complete the coaptation of the sur- 
faces, and to establish, little by little, the physiological movements of the 
joint. 

Other surgeons have confined their eiforts to the reduction of the dis- 
location, and they have, consequently, abandoned all those cases in which, 
owing to the complete absence of the natural socket, or to the want of 
sufficient mobility in the limb, the reduction was deemed impossible ; but 
Guerin has gone a step farther, and has sought to establish a new socket 
upon some point of the pelvic bones as near as possible to its natural 
articular fossa. " The means which I adopt," says Guerin, " are based 
upon a recognition of the processes which nature employs for the attain- 
ment of the same purpose, and of which mine are but an imitation. I 
have shown that the essential condition of the formation of artificial 
cavities is perforation of the articular capsule, and the placing in con- 
tact of the luxated extremity with an osseous surface, and that the con- 
dition of the maintenance of this abnormal rapport is the intimate ad- 
herence of the borders of the rent with the circumference of the new 
cavity. Now it appeared to me that art could realize, in all points, the 
conditions which preside at the spontaneous formation of artificial joints. 
To this end I commence by practising under the skin, and at the point 
corresponding to that where it is most convenient to fix the luxated ex- 
tremity, scarifications of the capsule, down to the bone to which it is 
attached. By this means the dislocated extremity is placed in immediate 
contact with the bony surface upon which it reposes. It makes upon 
this point a beginning of the work of organization resulting from the 
adhesion and fusion of the scarified points with the corresponding points 
of this surface. Then, in order to circumscribe and imprison the luxated 
extremity, in this place of election, I practise all about deep scarifica- 
which tend to excite the same work of organization and to estab- 

1 Dupuytren, op. cit., pp. 176-178. 



CONGENITAL DISLOCATIONS OF THE PATELLA. 991 

lish fibro-cellular adhesions between the incised borders o\' the capsule 

and the contiguous bony surfaces. 

••Finally, when the fibro-cellular adhesions are supposed to be suffi- 
ciently solid to resist the movements of the new articulation, .1 provoke 1 , 
little by little, the development of the cavity destined to embrace the 
luxated extremity by the means which nature herself employs in analo- 
gous circumstances: that is to say. by circumscribed and frequent move- 
ments of this articulation." 1 

The treatment ought to be commenced as early as possible, no exam- 
ples of success having been recorded in persons over fifteen years of age; 
while the youngest child whose treatment is reported as successful was 
three years of age. 

For the purposes of making the requisite extension, and of maintaining 
the bone in place, Pravaz (who does not, however, adopt Guerin's prac- 
tice of establishing for the head of the bone a new socket, but only seeks 
to reduce and maintain it in its old socket) has invented several forms of 
apparatus adapted to the different stages of progress in the treatment. 
Heine, of Cannstadt. Guerin, and others, have also suggested special 
contrivances for the same purpose; but no surgeon who understands fully 
the principle upon which the cure is supposed to be accomplished, will 
be at loss for apparatus suitable for making the necessary extension, or 
for maintaining the reduction when once it has been effected. 

The length of time required for the completion of a cure, where a cure 
is possible, must vary according to the age and health of the patient. 
and according to the pathological condition of the joint, and may be 
found to extend from a few months to one or more years. It is unne- 
cessary to say that where the accomplishment of the cure demands a 
period of several years, the treatment must be intermittent and greatly 
varied, so as to suit all the changing circumstances in the condition of 
the patient. 

Finally, if after a fair trial we fail to accomplish a cure, or if the con- 
dition of the child will not warrant even the attempt, we ought as fir as 
possible to seek to prevent an increase of the deformity by such mean- as 
our ingenuity may suggest, or by such judicious appliances and general 
management as we have seen recommended by Dupuytren. 

South says that he has seen one case of double dislocation in which 
the walking was at first extremely difficult, bul from the fifteenth year 
and onwards the patient so improved thai at the twentieth year scarcely 
n-ace of the peculiar gait could be discovered. 1 

s 14. Congenital Dislocations of the Patella. 

Palletta found a dislocation of the patella in the cadaver of a young 

man, which he supposed to be congenital. 1 Michaelis has reported tun 

- : one in a young man of seventeen years, and the other in a girl 

of fourteen, each of whom affirmed thai it had existed from birth. 4 

1 G-uenn, op. cit., 
- ith, Note to Cheliua, op. ''it., v..!. ii ; 
I' ■ E tatioTV Pat p. 91. 

M.- ; ( . ]: 66. 



992 CONGENITAL DISLOCATIONS. 

Both of these examples presented themselves at the hospital on account 
of hydrarthrosis of the knee-joints, and Malgaigne, who had himself 
Been a similar case, is disposed to regard them all as examples of path- 
ological rather than congenital dislocations. Periat reports a case in 
which the dislocation was only produced by walking, and in relation to 
the authenticity or pertinence of which Malgaigne seems also to entertain 
a doubt. 1 

South says that he has seen a congenital dislocation of both legs, in 
an aged man. The patellae rested entirely upon the outer faces of the 
external condyles, leaving the front of the knee-joint completely un- 
covered. When the limbs were extended the patellae could be easily 
made to resume their natural positions, but on the patient's making the 
slightest movement they were again displaced. The knees were very 
much inclined inwards, the feet outwards, and his gait was difficult and 
mi-ready." 

I h\ Samuel G. Wolcott, of Utica, N. Y., informs me that he has under 
observation a case similar to the one reported by South, in a healthy 
and otherwise well-formed and well-developed boy, set. 4. "When the 
legs are flexed the patellae slip outwards upon the external condyles of 
the femurs, and on extending the legs the patellae resume their positions 
in front of the knee-joints. This occurs at every step he takes. The 
knees are strongly inclined inwards, and the feet outw T ards. His step is 
very insecure, and if accidentally he hits his feet or legs against anything 
in walking, he invariably falls." 

The most remarkable example, however, has been reported by Dr. E. 
J. Caswell, of Providence, R. I., inasmuch as no less than five members 
of the same family have double congenital dislocations of the patellae. 
The man who was the subject of Dr. Caswell's special examination is 
43 years old, and possessed of a good constitution. The patellae lay 
upon the outer condyles, and are movable, performing their functions 
nearly as well as if placed in their proper positions. He walks without 
difficulty upon level ground, or upon an ascending plane, but great caution 
is required in descending. The right patella is longer and less movable 
than the left, and the muscles of both of his lower extremities are small. 

" In addition to his labor as an operative, he cultivates a small farm." 
Dr. Caswell examined his son and found the same malposition, but less 
marked than in the case of the father. The father then stated that his 
own father, his sister, and the son of his half-brother by the same father, 
had a similar deformity. 3 

Servier 4 relates a case of congenital dislocation of the patella associated 
witli other deformities, and both the father and the brother had dislocations 
of the patella. Zielewicz 5 has collected eight cases of congenital outward 
dislocation. To these examples P. Berger 6 has added three others. 

1 Periat, Malgaigne, op. cit, torn. ii. p. 932. 

I h. No e to Chclius, op. cit., vol. ii. p. 247. 
Caswell, Amer. Joum. Med. Sci., July, 1865. 

rvier, Gaz. hebd. de Med. et de Chir., avril 5, 1872. 
.if/.. Berliner Klin. Wochens., t. 6, p. 25, 1869. 
6 P. Berger, Art. K<<tule, Diet. Encyc. Sc. Med., 3d. ser., t. 5, p. 360. 



CONGENITAL DISLOCATIONS OF THE KNEE. 993 

Holthouse 1 mentions a case seen by himself, and Lannelongue 8 repo 

similar ease. 

§ 15. Congenital Dislocations of the Kne$. 

The head of the tibia has been found, at birth, dislocated forwards, 
backwards, inwards, outwards, inwards and backwards, outward- and 
backwards, and simply rotated inwards. 

Most of these dislocations were incomplete: and of them all. the dislo- 
cation forwards has been observed much the most often. 

A subluxation forwards of the head of the tibia has been seen by 
Guerin in a foetal monster, accompanied with extreme retraction of the 
extensor muscles of the leg. 3 Cruveilhier has dissected a foetus affl 
with a similar subluxation. 4 

In these examples the displacement forwards at the articular surface 
was but slight, and the anterior flexion of the limb inconsiderable: but 
when the dislocation is complete, or nearly so. the deformity is in all 
respects very much increased : as the following examples will illustrate. 

Dr. D. H. Bard, of Troy, Vermont, has reported an example of com- 
plete anterior dislocation of the tibia, seen by himself, in a new-born 
infant. The leg was found drawn forwards upon the thigh at an acute 
angle, so that the toes pointed toward the face of the child, and the bot- 
tom of the foot was directed forwards. By the application of moderate 
force, the limb could be straightened and even flexed completely. These 
motions inflicted no pain. It was especially noticed that in bringing 
down the leg from its position of extreme anterior flexion (extension) 
more force was required in the first part of the manoeuvre than in tin- 
last : and that if, having brought the leg down, it was left to itself, it 
immediately resumed the abnormal position, moving at firsl slowly, but 
after a time much more rapidly. 

The limb was confined by bandages for a short time, and it did not 
afterwards show any disposition to return to its unnatural position. The 
child did well and when it began to use its legs, no difference could be 
discovered between them. 5 

J. Youmans, of Portageville, N. Y.. reports a similar case whicb 
occurred in his own practice. A healthy woman was delivered, on the 
16th of August. 1859, of a full-grown female child, whose left kna 

impletely dislocated that the toes rested upon the anterior pari of 
the thigh near the groin. Dr. Youmans immediately took hold of the 
limb and brought it to its natural form, but ;i^ soon ;•- ho relinquished 
his hold, it flew back to its original position. Saving again straightened 
the leg it was retained in place easily by two pice- of whalebone tied 
upon";irh side of the thigh and body". Some soreness and swelling 
ensued, and h was some weeks before the splinl could bo ^.i\\-\y rem 
At the time of the report, Ocl 11, I860, tin- child the 

1 Holthouse, The I. 

2 Lannelongue, Ball. - I P 

* Cruveilhier. Atlas de l'Anal Pa 2e livr. f pi. 2. 

Bard, A 
Journ. 



CONGENITAL DISLOCATIONS. 

limb with as much freedom and dexterity as other children of her own 

age- 
fa the report particular attention is called to the disposition on the 
part of the limb to resume its unnatural position with a spring, showing 
contraction of the anterior muscles of the thigh ; to the fact that the 
patella of this knee was smaller than the other, and that the skin on the 
front of the knee was wrinkled as it is usually back of the knee in fat 
children. 1 

I have mentioned a case of congenital forward dislocation of both 
tibiae which came under my observation, in the section on congenital 
dislocations of the hip, and I have recently seen a case of congenital 
subluxation of both tibiee backwards, occasioned by contraction of the 
hamstrings. Section of the muscles restored the bones nearly to their 
normal position. 

Chatelain was consulted in relation to a similar case, in which the 
restoration of the limb to its natural position was also easily effected, 
and by means of three metallic splints, applied during about fifteen days, 
the cure was consummated. Chatelain directed, however, that the leg 
should be kept flexed upon the thigh eight days longer. 2 

Kleeberg found a child with the leg so much flexed forwards (extended) 
upon the thigh that the popliteal region became the lowest point of the 
limb ; in front and above the articular extremity of the tibia could be 
felt, and the condyles of the femur made a corresponding projection 
behind into the popliteal space. This was plainly an example of complete 
dislocation : and, contrary to what was observed in Bard's case, flexion 
of the limb backwards was difficult and painful. 

The treatment was commenced by securing the limb in a straight 
position by means of a splint and roller; subsequently, Kleeberg carried 
the limb back to an obtuse angle, and finally, it was kept eight days in 
a position of extreme flexion. A complete cure was said to have been 
accomplished in about two weeks. 3 

Richardson and Porter 4 report a case of congenital dislocation of the 
tibia forwards, in which the leg was carried to a right angle with the 
thigh. Reduction was easily effected and maintained by a roller. The 
cure u;is effected in about fourteen days. They report also another case, 
in which the anterior hyperextension was such that the leg could be laid 
upon the thigh. The cure was effected in ten weeks by the same means. 

Bertin 8 found a child at birth with a displacement similar to the second 
example seen by Richardson and Porter, and in whom, under the use of 
massage and bandaging, all traces of the deformity disappeared in fifteen 
days. At the end of seven years the cure remained complete. 

In a case -con by Motto, 6 where the heel touched the corresponding 
shoulder, the leg being turned on its axis, the reduction was easily effected, 
and being maintained by a bandage, the cure was effected in about fifteen 

1 Y/oumans, 15. .-ton Med. and Surg. Journ., Oct. 25, 1860, vol. lxiii. p. 250. 

hatelain, Bibliotheque Med., torn. lxxv. p. 85. 
■ Kleeberg, Malgaigne, op. cit., p. 983. 

* Richardson and Porter, Boston -Mod. and Surg. Journ., Sept 16, 1875. 
tin, Union Med., 14 Oct., 1880. 
tfotte, Bull. Acad, royale de Belgique, 3d ser., t. 10, No. 2. 



CONGENITAL DISLOCATIONS OF THE KX! 995 

days. After three years no traces of the deformity existed, and the 
functions of the limb were perfectly restored. 

Moos 1 saw in a child two and a half years old, a congenital displace- 
ment, in which the leg was extended forwards to a righl angle with the 
thigh. The dislocation had been reduced when the child was six weeks 
old, but in spite of an apparatus continuously applied, there still con- 
tinued a tendency to subluxation forwards, the knee inclined backwards, 
and the foot was everted. 

Guenior communicated to the Surgical I Paris two examples 

of congenital incomplete forward dislocation of the tibia. In both i 
a cure was speedily effected by very simple means. At the same Beance 
Gueniot presented a case observed by Perier, almost precisely analogous 
with those seen by himself, but in which case, in spite of apparatus, the 
deformity persisted at the end of about six weeks, and without manifest 
improvement. 

Gruerin has seen a subluxation backwards, accompanied with a slight 
rotation of the head of the tibia outwards, in a girl fourteen years old : 
and which, he affirms, was congenital, characterized by a permanent 
flexion (backwards) of the leg upon the thigh, and a sliding of the con- 
dyles of the tibia backwards. 

This girl was under Guerin's treatment, but with what result is not 
stated. 3 

Chaussier found both tibiae displaced backwards in an infant otherwist 
deformed. 4 

Robert speaks of an example of lateral subluxation in a man. which 
had existed from birth. The right knee was thrown inwards, and the 
left outwards. 5 

Guerin "operated" publicly upon a child, two years old. who had a 
congenital dislocation of the head of the tibia backwards and inwards, 
accompanied with a slight rotation of the leg inwards. 1 ' In what manner 
he operated, and with what result, he duo- not inform as. 

The same writer speaks of a subluxation backwards and outwards, 
with rotation in the same direction, a deformity which, he affirms, IS 
very frequent, and which appears especially after birth, although the 

- which produce it have given their first impulse during intra- 
uterine life. 

The case quoted from Robert, by Malg an example of dis- 

location inward-, seems T " have been rather ;i case of semi-rotation of 
the articular surfaces, the inner condyle being thrown hack int.. the 
popliteal space, while the outer condyle -till retained it- natural : 
tion. 

' Moos, Archiv fur Klin. Chir., Bd. 

- (, B 
' riierin, but Lee I. ' 

4 Chaussier, Malg 88 i. 

"I: .-. M _ 

■ ' . uerin . BUT I' - 



996 CONGENITAL DISLOCATIONS. 



§ 16. Congenital Dislocations of the Tarsal Bones. 

ruder this general term may be included all those varieties of sub- 
luxation of the several bones which compose the tarsus, and which are 
known as examples of talipes or club-foot; such as tibio-astragaloid dis- 
locations, astragalo-scaphoid, calcaneo-astragaloid, calcaneo-cuboid, etc. 

Although these deformities may properly enough claim a place in a 
chapter on congenital dislocations, they have so long been the subjects 
of special treatises as to justify their exclusion from the present volume. 

§ 17. Congenital Dislocations of the Toes. 

Observed occasionally at the metatarsophalangeal articulations; the 
articular facets of the first phalanges suffering a subluxation upwards, 
or laterally upon the corresponding metatarsal bones. 

Guerin has noticed especially a congenital lateral subluxation of the 
great toe. 1 

1 Guerin, op. cit., p. 34. 



INDEX. 



PART I. FRACTURES. 



ABSCESS in fracture of the sternum. 
200 
Acetabulum, 407 
Acromion process, 243 
Amesbury's thigh splint, 471 
Anaesthetics, use of, in diagnosis, 46 
Anaplasty in fractures of the septum na- 

rium, 120 
Anatomical neck of humerus, 251 
Anchylosis after Colles's fracture, 337 

after fractures of elbow, 316 

after fracture of patella, 546 • - 

of knee, 526 
Antiseptic dressings, 80 
Apparatus immobile, 71 
Arytenoid cartilages, fractures of, 167 
Astragalus, 604 
Asymmetry of long bones, 470 
Atlas, 193 
Atrophy -of bone,' senile, 37 

surgical neck of humerus, 266 

neck of femur, intracapsular, 420 

tibia above tubercle, 567 
Axis, 

and atlas, 194 

BADLY united fracture of leg, 00:5 
fracture of radius. 333 
Barton's bran dressing, 82 
Base of acetabulum, 408 

of condyles of femur, 515 

of condyles of humerus, 289 
Bauer's wire splint-. 697 
Bean, lower jaw apparatus, 151 
Bending of bones. 96 

Bigelow, stellate fracture of lower end of 
radio- . 331 

riin of acetabulum, ll \ 
Boardman. fracture of zygoma. 131 
Body of the scapul 
Bodies of the 1 79 

Bond's elbow splinl 

radius split.- 

worth, Frank, tracheotomy in frac- 
ture of lower jaw. 186 
Box for \d'i. 
Beyer's thigh splint, \~'i 



Brainard, perforator, ml' 
Buck, lower jaw. 1". 1 
thigh splint, 47'.' 
Burge, patella, 558 



CALCANEUS, 606 
Carpal bones, 391 
Cartilages of the ribs, 208 
Cervical ligaments, strain 

vertebra?, bodies of five lower, 184 

axis, 190 

atlas, 193 

atlas and axis, 194 
Children, fracture of femur, old 
Chronic rheumatic arthritic 186 
Clark, fracture of humerus. 283 
Clavicle, 209 

partial fracture.-. 
Cline, trephining vertebra, 176 

fracture of atlas, 193 
. fracture-bed, 
Coccyx, 416 
Colles's fractui • 
Comminuted fractu: 
Common signs of fracture, 12 

Compound frl 
forearm, :;:-l 
thigh, 616 

patell 

tibia and flbula, 680 

J810D of spinal marrow. I 

Condyles of humerus, 801 

internal. 

external, 818 

base 

of f. 

external. 
internal, ••'_'•"> 
.". l "> 

I 

neck of femur within i 

1 



998 



INDEX. 



Coronoid process of ulna, 365 

Cotyloid cavity, 408 

Crandall, extension, fracture of leg, 595 

Cricoid cartilage, 167, 168 

Crosby, femur, external condyle, 523 



DANIELS'S fracture-bed, 503 
Deformities of legs, 602 
Delayed or non-union, 84 
Dennis, F. S., fracture of inferior max- 
illa, 139 
Denticulated fractures, 36 
Dextrine, 72 
Diagnosis, general, 42 
Dieffenbach, tenotomy in fracture of ole- 
cranon process, 364 
Dislocation of humerus, differential diag- 
nosis, 268 
Dorsal vertebra}, 183 
Dorsey, fracture of patella, 556 
Dugas, sign of dislocation of humerus, 

268 
Dupuytren's case of fracture of a dorsal 
'vertebra, 183 
body of a lower cervical vertebra, 

183 
dressing for fracture of fibula, 578 



ELBOW splint, Phvsick's, 295 
Kirkbride's, 295 

Rose's, 296 

Welch's, 296 

Bond's, 296 

the author's, 297 
Else, fracture of axis, 190 
Embolism, venous and fatty, 60 
Emphysema in fracture of ribs, 205 
Epicondyle of humerus, external, 309 

'internal, 302 
Epiphyseal separations, 37 

acromion, 244 

humerus, upper end, 259 
lower end, 290 

olecranon process, 356 

femur, upper end, 423 
lower end, 528 

trochanter major, 454 

tibia, 567 
Epiphyses, sternum, 195 

scapula, 245 

humerus, 260 

radius, 366 

ulna. 

os innominatum, 399 

femur, 418 

tibia. 567 

fibula, 572 
Epitrochlea, 302 
Etiology, general, 87 
Eve, non-union of ribs, 204 • 

patella, 666 
Exciting causes, general, 38 
Experiments on bending 

on partial fractures, 102, 105 



External epicondyle of humerus, 309 
condyle of humerus, 313 
femur, 523 
Extension of thigh bv adhesive plaster, 
502, 505 



FANNING, N., humerus, 278 
Fatty embolism, 60 
Fauger, Colles's fracture, 342 
Felt splints, 69 
Femur, 418 

neck, within capsule, 420 

upper epiphysis, 423 

neck, anatomy of, George K. Smith, 
435 

differential diagnosis, 449 

without capsule, 445 

trochanter major and base of neck, 
454 

epiphysis of trochanter major, 456 

shaft, 458 

lower third, 516 

measurement of, 469 

in children, 510 

external condyle, 523 

internal condyle, 525 

between condyles, 527 

base, and between the condyles, 527 

delayed and non-union, 530 

separation of lower epiphysis, 528 
Fibula, 572 
Fingers, 395 
Fissures, 108 

neck of femur, 419 
Fitch, fracture of lower jaw, 154 
Flagg's thigh apparatus, 478 
Forearm, 318 

Four-tailed bandage for broken jaw, 156 
Fractures, 35 

general etiology, 37 

general semeiology and diagnosis, 42 

repair of, 46 

general prognosis, 52 

general treatment, 61 

delayed union, 84 6^/, $J9 ■ 5T L Q 

incomplete, 96 
Fracture-beds, 503 

Jenk-, 503 

Hewson, 503 

Barton, 503 

Coates, 503 

Daniels, 503 

Burges, 503 

Crosby, 504 
Fracture-box, 599 



GANGRENE, after use of immovable 
apparatus, 74, 489, 512 
after fracture at base of condyles of 

humerus, 294 
Dupuytren's cases after fracture of 

radius, 350 
Robert Smith's cases, 352 
Norris, 353 



INDEX. 






Gangrene — 

after fracture offorearn 

patella. 565, 559 

le^- and thigh, from ti^ht roller, 353, 
485, 4- " 
General division of fractures, 35 

etiology of fracture-. 37 

semeiology of fractures. 44 

prognosis of fractures, 52 

treatment of fractures. 61 
Gibson, inferior maxilla. 155 
Gilbert, apparatus for broken femur, 4S1 

leg. 595 
Glenoid cavity of scapula. comminuted. 242 
Gout, cause of fracture. - 
Granger, fracture of epicondyle, 304 
Greater tubercle of humerus, 257 
Gum-shellac splints 
Gunshot fractures, 613 

treatment in, 615 
Gutta-percha splints, 70 



HARROLD. lumbar vertebra 
Hartshorne, Edward, clavicle, 225 
Hartshorne, Joseph E.. thigh apparatus, 

480 
Hays, radial splint. 342 
Havward, lower }aw. 146 
Head of radius, 318 

and anatomical neck of humerus, 251 
Head and neck of humerus, longitudinal 

fracture, 257 
Hereditary fragility, 38 
Hewson, fracture-bed. 503 
Hodge, thigh spin. 
Hodgen"s fracture-cradle. 

wire suspension splint, •' 
Horner, thiich apparatus 
Hot wal 
Humerus, 250 

anatomical neck, 251 

head and neck, 251 

tubercles, 2 

longitudinal fracture of head and 
neck. 

surgical necl 

upper epi: 

differential diagnosis, 268 

shal- 
lower epiphysis, 2 

base of condyles, 

with splitting ofcondyl< 

condyles, 

internal epicondyl 

external epi' 

internal condyle, 

external condyle, 

delayed union. \ 

dislocation 
Hunt, Wm., fracture of larynx, 170 

styloid procesa of radiu 
Hutchinson, leg splint, 
Hyde, F. E., fractures 

441, 445 
Hyoid bone, 160 



[L1TM 

1 Immovable apparatus. 71 

patella 

leg, 

thigh, 

dangers of, 74, 

Impacted fractures . 

head and neck of humerus. 251 
tubercles, 256 r 

neck of femur within capsuli 

without the capsuli 
radius 

Incomplete fractures * 

Inferior maxilla. 133 

Interstitial absorption of neck 

436 3 

Internal condyle of humerus, 310 / 
femu: 

Interdental splints, 147 

Intrauterine fracture, 3 

Ischium, 403 



JKSON, acromion process, 244 
Jenks, fracture-be 

Johnson, neck of femur, I "_' 



lv 



EY, lumbar vertebi 
Kingsley, fracture 



LAXGE. separation of lower epiphysis 
of humerus. 291 ' * 

Larynx, fracture of, 165 
Lausdale, patella. 557 £ 

Lente, fracture of dorsal vertebr 
femu: 
non-union 
pelvis 

-. splint for radiu-. 
Listerism, v " 
Liston. thigh Bplint, 

leg splint, 
Lonsdale, extension in fracture of hu- 
merus, 282 
patella 
■ jaw, 188 



MA LAB bone, 121 

patella 
of leg, 801 

i i ". 
Maxill . i'24 

infer! 

of tl 

811 



1000 



INDEX. 



Metallic splinl 

Mollities ossium, cause of fracture, 38 
Monahan, fracture of astragalus, 604 
( Jolles's fracture, 332 
fracture of clavicle, 228 
Morbus coxae senilis, 436 
Muhlenberg, tables of ununited fractures, 

95, 1 12, 218, 280, 531, 569, 585 
Muscular action, cause of fracture, 39 
Mutter, neck of radius, 321 



VfECK of femur, 419 
1\ within capsule, 420 

prognosis, 430 
Gr. K. Smith on, 435 
without capsule, 445 
Neck of humerus, anatomical, 252 

surgical neck, 259 
Neck of lower jaw, 135, 159 
of radius, 320 
of scapula, 242 
Neill. maxilla, superior, 129 
coracoid process, 247 
thigh, 476 
leg, simple fracture, 593 

compound fracture, 594 
ton, radial splint, 341 
Nerves, conditions of, causing fractures, 

38 
Non-union. 84 
clavicle, 218 
femur, 529 
fibula, 576 
humerus, 279 
lower jaw, 142 
patella. 536 
ribs, 204 
tibia, 

tibia and fibula, 585 
Norris, George W., delayed and non- 
union, 84 
astragalus, 607 
gangrene from bandages, 353 
tibia, 571 

fracture of, 113 
wire splints, 66 
s b apparatus, 473 







DONTOID process of axis, 190 
(Edema alter removal of dressings, 



■ 356 
epiphyseal separation, 365 
tenotomy, 36 1 

-!. 113 



P\' KAKD. J. A., clavicle, 226 
inferior maxilla, tenotomy, 143 
Palmer's thigh splint, 475 
Paralysis after fracture of spine, 171 
inferior maxilla, 138 
clavich 



Paralysis after fracture — 

internal epicondyle of the humerus, 
305, 307 

base of condyle, 293 

upper end of fibula, 576 
Partial fracture, 99 
Patella, 534 
Pelvis, 399 

traumatic separations, 399 
Phalanges of fingers, 395 

toes, 612 
Plaster of Paris, see Immovable Dre 
Prognosis, general, 52 
Pubes, 399 
Pulmonary venous embolism, 61 



RADIUS, 318 
Kadius and ulna, 380 
Eeduction of fractures ; general consider- 
ations, 61 
Refracture of badly united legs, 603 
Kepair of fracture, 46 
Resection for badly united fractures, 602 
Rheumatic arthritis, chronic, 436 
Rhinoplasty, 120 
Ribs, 202 

cartilages of, 208 
Rim of acetabulum, 411 
Rodet, neck of femur, 421 
Rogers, trephining vertebra?, 177 
Roller, 63 
Rose, elbow splint, 296 



OACRUM, 415 

Sacro-iliac symphysis, 416 

Salter's cradle for leg, 598 

Sargent, separation of upper maxillary 

bones, 124 
Say re, L. A., clavicle, 229 
prognosis, 55, 464 
Scapula, 237 

bodv, 237 

neck, 242 

acromion process, 243 

coracoid process, 247 

epiphyses of, 245 
Scultetus, bandage, 64 
Semeiology, general, 42 
Senile atroph} 7 , see Atrophy of Bone. 
Septum narium, 118 
Setting bones, 62 
Seutin, dressing, 71 
Shaft of humerus, 277 

from muscular action, 277 

femur, 458 

radius, 324 

ulna, 356 
Shellac splints, 69 
Shoulder-joint; differential diagnosis of 

accidents, 268 
Shrady, radius splint, 341 
Side splints, 65 

Simmons, extension apparatus, 484 
Sling for broken jaw, 156 



INDEX. 



1001 



Smith. E. P.. radial splint. 342 

Smith. Nathan R., fracture of femur. 

473 
Smith. Robert, head of humerus 
Smith. Stephen, fracture of lower jaw. 
134 

odontoid process of axis, 192 
Smith, George K., insertion of capsule of 

hip-joint, etc., 43-5 
Spinal marrow, concussion. 186 
Spinous processes, vertebra?, 171 

ilium. 171 
Splints. 65 
Starch bandage. 71 
Sternum. 105 

diastasis. 195 
Styloid process of radius. 331 

of ulna, 380 

gjical neck of humerus, 259. 270, 274 
Swing-box for leg. 
Svmphvses of pelyis, 399 

ofpubes, 399 

sacro-iliac, 416 
Symphysis pubis, separation of. 399 
Syphilis, cause of fracture, 38 



TARSUS, 604 
astragalus, 606 
calcaneum, 606 

Tenotomy in fractures of olecranon pro- 
cess, 364 

Tlvmpson, fracture of lumbar vertebra 1 , 
1-2 

Thyroid cartilage, 105 

Thyroid and cricoid cartilages, 167 

Tibia. •" 

Tibia'and fibula, 580 

T es, 612 

Trader"s suspension apparatus. 599 

Transverse processes of spine, 173 

Treatment of fractures, general, 61 

Trephining for fracture of vertebrae, 17') 

Tripoli th. 73 

Trochanter major. 454 

Trochlea of humeri, 

Tubercles of hum. 

•r. patella splint. 



ULN A. reset tion :'. 372 
[Jlna, 356 
shaft. 876 
coronoid pi 

olecranon - 

styloid p: 
Upper epiphysis, humerus 

femur, 42"> 
Upper maxillary bones, 124 



VANDEVENTER, fracture of vertebral 
arch, 174 
Van Wagenen's suspension apparatus, 591 

Velpean, mode of dressing fractures with 

dextrine and roll 
Venous embolism, 61 
Vertebral arches. 174 
Vertebrae, 171 

spinous processes. 171 
transverse processes L73 
vertebral arches, 174 
bodies. 170 

lumbar. 181 
dorsal, 183 
cervical. 184 
axis, 190 
atlas, 193 
atlas and axis, 194 



WACKERHAGEN, fractured leg, 592 
"Warren on anchylosis at elbow- 
joint, 316 

Water, warm and hot, 82 

Water-beds, 189 

Veils, internal condyle of femur. 525 

Wire-beds, 189 

Wire-splints, 66 

"Wire rack for fracture of leg, 600 

Wooden splint 

Wrist, 391 

Wyeth, patella -plii. 



7FCKERKANDL, epicondyl 
L 310 



Zygomatic arch. 180 



1002 



INDEX. 



PART II. DISLOCATIONS. 



AGNEW, D. H., rupture of axillary 
vein, 716 
Anaesthetics, 637 

Ancient dislocations, 629 

inferior maxilla, 640 

spine, 652 

clavicle, outer end, 677 

humerus, 706 

head of radius forwards, 746 

radius and ulna backwards, 762 

thumb, 796 

femur, 872 
Andrews, inferior maxilla, 638 
Ankle-joint, 916 
Anomalous dislocations of the hip, 863. 

See Femur. 
Anterior oblique dislocations, 867 
Astragalo-calcaneo-scaphoid dislocations, 

943 
Astragalus, 931 
Atlas, dislocations of, 660 
Axillary artery, rupture of, 712 

vein, rupture of, 715 
Ay res, dislocation of cervical vertebra, 658 



BATCHELDEK, head of radius, 748 
thumb, 800 
Biceps, rupture or displacement of, 739 
Bigelow, H. J., on dislocations of hip, 813 
Blackmail, ancient dislocations of hu- 
merus, 712 
femur, 875 
Bloxham's dislocation tourniquet, 829 
Brainard, reduction of ancient dislocation 
of elbow, 762 



CA L< A XEUM, dislocation of, 945 
Canton, radius and ulna forwards, 
775 
Carpus, 779 

backwards, 782 
forwards, 785 
congenital, 984 
Carpal bonee among themselves, 789 

-metacarpal articulations, 791 
Cartilages, of ribs from sternum, 665 
Of ribs upon one another, 666 
in knee-joint, 913 

ell, congenital dislocation of patella, 
992 

le, dislocations of, 667 
sternal end forwards. 667 
rnal end upward-. 671 
sternal end backwards, 673 
omial end upwards, 675 
acromial end downwards, 681 
under coracoid pr 



Clavicle — 

both ends, 684 

congenital, 978 
Clove-hitch, 636, 798 
Compound pulleys, 637 
Compound dislocations of the long bones, 
954 

reduction in, 959 

non-reduction in, 962 

amputation in, 962 

tenotomy in, 963 

resection in, 964 
Congenital dislocations ; general observa- 
tions and history, 970 

general etiology, 971 

inferior maxilla, 974 

spine, 977 

pelvic bones, 977 

sternum, 978 

clavicle, 978 

shoulder, 979 

radius and ulna backwards, 983 

head of radius, 983 

wrist, 984 

fingers, 985 

hip, 985 

patella, 991 

knee, 993 

tarsus, 996 

toes, 996 
Cooper, Sir Astley, method of reducing 

dislocation of humerus, 702 
Coxo-femoral dislocations, 808. See Fe- 
mur. 
Crosby, dislocation of thumb, 800 

ancient dislocation of elbow, 763 
Cuboid, dislocations of, 947 
Cuneiform bones, dislocation of, 948 



DAMAINV1LLE, statistics of disloca- 
tions of femur, 830 

Darby, shoulder, 699 

Davis, G-. P., vertical dislocation of pa- 
tella, 899 

Direct causes of dislocations, 631 

Dislocations, 629 

Division and nomenclature of disloca- 
tions, 629 

Double dislocation of lower jaw, 640 

Dougherty, patella, 901 

Dynamometer, 829 



ELBOW-JOINT, 752 
Everted dorsal dislocation of femur, 
818 
Exciting causes, general, 631 
Extension by a twisted rope, 636, 828 



INDEX. 



L003 



FEMUR, dislocation of. SOS 
dislocation on dorsum ilii, 810 

reduction by manipulation, 819 
reduction by extension. B2' 
dislocation into great ischiatic notch, 

841 
below the tendon. 844 
dislocation into the foramen thvroid- 

eum, 849 
dislocation upon the pubes, s o7 
anomalous dislocations of the femur, 
863 
downwards and backwards upon 

the body of the ischium, 868 
downwards and backwards into 

lesser ischiatic notch, 869 
behind the tuber ischii, 869 
dislocation directly up, 863 
directly down, 870 
forwards into perineum 
ancient dislocations, v "'_ 
partial dislocations, 880 
with fracture, 881 
in children, 808 
congenital, 985 
voluntary, B84 
Fenner, dislocation of femur on dorsum 

ilii. S12 
Fibula, upper end forwards, 027 
backwards, 928 
' lower end, 930 
" Fifth "' dislocation of femur, 869 
Fingers, dislocations of first phalanx, 804 
second and third, 805 
congenita I, 
voluntary, 890 
Foot, dislocation outwards, 916. See Tibia. 
Fountain, dislocation of femur upon 
pubes, 861 

GENERAL division, 629 
direct or exciting causes, 631 
predisposing causes, 630 
prognosis, 634 

pathology, 633 
treatment, 
syru . 
Ger-ter, dislocation of longhead of biceps, 
742 

n, ancient dislocation of humerus, 
714 
Gilbert. A. W., dislocation of lower jaw, 

Grant, astra^alu-. 
Graven, dislocation of dorsal vertebi 
Gunn. Si< -•■-. lislocation of thigh on dor- 
sum ilii, 81 

ischiatic notch. 

foramen thyroideum, - 

upon pub<-- 

shoulder downwards, 688 



H 



ART, dislocation of astr;._ 

Hartshorne, reduction of humerus by 
manipulav 



Head upon the at la-. 

Haynes, S., double dislocation of cla? 

Hickerman. cervical vert 
Hip. congenital dislocations < f, 986 
Hod^e, statistics of dislocations of the fe- 
mur. B08, 1 
Horner, partial dislocation of fourth cer- 
vical vertebr 
Howe, reduction of dislocation of the bip 

by manipulation, 822 
Humerus, dislocati 

double, 719 

downward - 

forwards, 71'.' 

fracture in reduction, 716 

backward-. 

upwards, 734 

parti.-. 

ancient, 706 

rupture of axillary artery, 712 

rupture of axillary vein, 71"> 

rupture of axillary artery and vein, 
715 

cerebral congestion. 71") 

injury to axillary nerves, 716 

avulsion of arm, 716 

inflammation. 716 

congenital, 979 
Humero-scapular dislocation, 685. See 

H'nn eras. 
Hutchison, dislocation of femur. 8 12 
Hyoid bone, dish -cation of, 646 



TLIO-FEMORAL ligament, 814 
1 llio-pubic dislocation of femur. 857 
Indian "puzz 
Inferior maxill 
double distli 
single dislocati* »n, 6 1- 
genital dislocation, 
reduction of dislocation of bip by 
manipulate 
Internal derangement of kn» 
Ischio-pubic dislocation of femi 
Ischiatic dislocation of femur, B 



rARVIS'fi 

ft J a.'. 

KtRKBRIDB, dislocation at th< 
upon posterior part of the body of 
the ischium 

i unar cartil i 

Krackowizer, dislocation of head of ra- 

; i \ 

LA M< >'l H 

■ boul- 



1004 



INDEX. 



Lente, fifth cervical vertebra, with frac- 
ture, 054 

fifth cervical vertebra, without frac- 
ture, 654 

femur directly upwards, 866 
Levis, reduction of dislocation of thumb, 

801 
Ligamentum patella), rupture of, 902 
Lister, rupture of axillary artery, 714 
Long bones, compound dislocation in, 954 
Long head of biceps, displacement of, 739 
Lower jaw, 637 

double dislocation, 638 

single dislocation, 642 

simulating luxation of, 645 
Lumbar vertebrae, 648 
Lunare, 791 



MAGNUM, 790 
and cuneiform, 730 
Markoe, on reduction of dislocation of fe- 
mur, 824 
head of radius backwards, 749 
femur with fracture reduced, 883 
Maxilla, inferior, congenital, 974 
Maxson, dislocation of cervical vertebrae, 

657 
Mercer, on partial dislocations of hu- 
merus, 741 
Metacarpus, 791 

Metacarpophalangeal articulation, 795 
Metatarsus, 950 
Middle carpal dislocation, 791 

tarsal dislocation, 946 
Moore, on reduction of dislocation of fe- 
mur, 813 
ulna, 332 
Mussey, dislocation of the thumb, 799 
ancient dislocation of elbow, 763 



V oRRIS, George W., ancient disloca- 
^\ tions of the humerus, 717, 722 

dislocation of humerus mistaken for 

a contusion, 722 
compound dislocation of thumb, 803 
Norris, Basil, astragalus, 940 
North, N. C, double dislocation of clavi- 
cle, 684 



II' 



CCIPITO-ATLOIDEAN disloca- 
tions, 663 



PACKARD, John H., dislocation of 
great toe, &58 
Pardee, E. L., double dislocation of hu- 

mer is, 720 
Parker, head of humerus in subscapular 
fossa, 720 
backwards, 728 
head of radius backwards, 749 
head of radius outwards, 751 
femur into perineum, 871 



Patella, outwards, 893 

inwards, 896 

on its axis, 897 

upwards, 902 

downwards, 903 (note) 

spontaneous, 892 

congenital, 991 
Pathology, general, 633 
Pelvis, congenital, 997 
Peroneo-tibial, 930 
Pettit, A., dislocation of tibia, 908 
Phalanges, thumb and fingers, 795 

toes, 952 
Pisiform, 790 
Pope, dislocation of femur into perineum, 

871 
Predisposing causes, general, 630 
Prognosis, general, 634 
Pseudo-luxations of inferior maxilla, 645 
Pulleys, 637 

Purple, dislocation of cervical vertebrae, 
654 



Q 



UADRICEPS, rupture of, 903 



RADIUS, head dislocated forwards, 743 
backwards, 749 
outwards, 751 
downwards, 751 
congenital, 983 
Radius and ulna, dislocation backwards, 
754 
congenital, 983 
outwards, 765 
inwards, 772 
forwards, 775 
Radius forwards and ulna backwards, 777 
Radio-carpal articulation, 779. See Car- 
pus. 
Radio-ulnar articulation, inferior, 786 
Reid, reduction of dislocation of femur by 

manipulation, 824 
Ribs from vertebrae, 664 
from sternum, 665 
one cartilage upon another, 666 
Rochester, sternal end of clavicle upwards, 

671 
Rudiger, dislocation of dorsal vertebra?, 

651 
Rupture of quadriceps femoris, 903 
Rupture of biceps, 739 
Rupture of ligamentum patellae, 902 



QACRO-SCIATIC dislocation of femur, 
O 841 

Sanson, third cervical vertebra, 654 
Sayre, ancient of hip, 795 
Scaphoid, dislocation of, 947 
Scapula, 889 

Schuh, dislocation of cervical vertebra, 655 
Shoulder, dislocations of, 685. See Hu- 
mencs. 



I X D E X . 



1005 



Single dislocation of lower jaw. 642 

•• Sixth " dislocation of femur. - 

Skey. method of reducing dislocation of 

humerus. 703 
Smith, Nathan, on reduction of disloca- 
tion of the humerus, 700 
reduction of femur by manipulation, 
821 
Smith, H. H., on reduction of humerus, 

70-3 
Spencer, dislocation of cervical vertebra, 

655 
Spine, 647. See Vertebra:. 
Spontaneous dislocations. See Voluntary 

Dislocations, p. 884. 
Squier, T, H., dislocation of radius and 

ulna inwards, 774 
Sternum, 673 

congenital, 978 
Sternberg, vertical dislocation of patella, 

899 
Subcoracoid dislocation of humerus, 719 
Subclavicular dislocation of humerus, 719 
Subcotyloid dislocation of femur, 870 
Subluxation of the jaw, 645 
Subglenoid dislocation of the humerus, 686 
Subpubic dislocation of femur, B49 
Subspinous dislocation of humerus. 728 
Swan, dislocation of dorsal vertebra, 652 
Symptomatology, general, 632 



rpARSUS, 931 

1 astragalus, 931 

astragalo-calcaneo-scaphoid. 943 
calcaneum. 945 
middle tarsal dislocation, 946 
os cuboides. 947 
os scaphoid, 
cuneiform bones, 948 
congenital, 
voluntary. 
Tendons, dislocation of. 

_ 808. See J- 
Thumb, first phalanx, 795 

backwards 

forwards, - 
second phalanx, 805 
Tibia, dislocation of upper end 

backward-, 904 

forwards. 

outv. 

inwards, 910 

backward- and outward-. r*l 1 

forwards and outwards, 912 

forward- and inwards, 912 

by rotation. 918 
genital, '■<'■'■'• 
lower end in ware - 

outward-, 921 

forward-. 

backward - 



Tibio-tarsal dislocations. 916 
Toes, 952 

congenita'. 
Treatment, genera 
Tripod for vertical extension of femur, 

840 
Trowbridge, head of humerus backward-. 

728 
Twisted rope extension. I 



ULX'A. upper end backward-, 
inward-, 768 
lower end backwards. 
forwards, 787 

Unilateral dislocation of lower jaw, 642 



VAX BUBEN, W. lb, dislocation <>\ 
humerus backwards, 728 
reduction of femur by manipulation, 

833, 000 
Varick, T. R , radius and ulna outward-. 

Vertebra?, 647 

lumbar, 648 

dorsal, 650 

six lower cervical 

atlas upon axi- 

head upon atlas, 668 

congenital dislocation-. 977 
Voluntary and spontaneous dislocations, 
884 

inferior maxilla. 645, 974 

Bcapul 

humerus, 890 

wrist-joinl 

phalanges of finger 

hip-joint, E 

knee-joint, 892 

ankle-join: 

tarsal-joint- 

patella, 892 



WAKM 
Warren, C. EL, the contortionist, 
voluntary dislocation, - 
Waterman, T., reduction of elbow 
- m, dislocation of patella outu 

Wells, dislocation of tibi 
Windlac 

■ . 

humerus, with fracture 



. LIGAMEN1 
of kne< 



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Operative. By Samuel D. Gross, M.D., LL.D., D.C.L., Professor of Surgery 
in the Jefferson Medical College of Philadelphia. Sixth edition, thoroughly 
revised and greatly enlarged and improved. In two large and beautifully printed 
imperial octavo volumes containing 2382 closely-printed pages, with 1623 engravings. 
Leather, with raised bands, $15.00; half Kussia, $16.00. 



As indicating the care with which the revision has 
been carried out it may be stated that the chapters 
on the respiratory organs, the eye and '.he ear have 
respectively received careful revision at the hands ot 
Dr. J. Sobs Cohen, Dr Geo C. Harlan and Dr 
Chas. H Burnett; while Professor Edward C 
Seguin, of New York, furnishes a section on cranio- 
cerebral topography— a subject new to books of sur- 
gery, Dr. Battcy has supplied valuable matter rela- 
tive to oophorectomy and Dr. Lewis Hall Sayre, 
one relative to the application of the plaster-jacket 
in the treatment of spinal diseases The index, 



which is of an elaborate character, has been care- 
fully prepared by Dr. R J. Dunglison. That Pro- 
fessor Gross's work worthily occupies a standard 
position is the just reward of the intelligent, con- 
scientious and persevering labor which he has for 
many years bestowed upon the study and practice 
of his profession, of the ability and good judgment 
with which he has investigated the data of others as 
well as his own conclusions, and of the care with 
which he has applied his knowledge to practice. — 
The British Medical Journal, March 24, 1883. 



FLINT'S PRACTICE, with an Appendix.— Just Ready. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. With an Appendix on the 
Researches of Koch and their bearing on the Etiology, Pathology, Diagnosis and. 
Treatment of Pulmonary Phthisis. By Austin Flint, M.D., Prof, of the Principles 
and Practice of Medicine and of Clinical Medicine in Bellevue Hosp. Med. Coll., 
N ew York. Fifth edition, revised and largely rewritten. In one large octavo volume 
of 1150 pages. Cloth, §5.50; leather, $6.50 ; very handsome half Russia, $7.00. 

No text-book is more calculated to enchain the way adapted to serve not only as a complete guide, 

interest of the student, and none better classifies the but also as an ample instructor in the science and 

multitudinous subjects included in it. It has, already, practice of medicine. The style of Dr. Flint is 

so far won its way in England, that no inconsider- always polished and engaging The work abounds 

able number of men use it alone in the study of pure in perspicuous explanation, and is a most valuable 

medicine; and we can say of it that it is in every text-book of medicine. — London Medical News. 



THOMAS ON WOMEN.-New and Revised Edition. 

A Practical Treatise on the Diseases of Women. By T. Gaillard 
Thomas, M.D., Professorof Obstetrics, etc., in the College of Physicians and Surgeons, 
Xew York. Fifth edition, thoroughly revised and rewritten. In one large and 
handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00 ; feather, 
$6.00; very handsome half Russia, raised bands, $6.50. 

The words which follow "fifth edition" are in 
this case no mere formal announcement. The alter- 
ations and additions which have been made are both 
numerous and important The attraction and the 
permanent character of this book lie in the clear- 
ness and truth of the clinical descriptions of diseases ; 
the fertility of the auihor in therapeutic resources, 
and the fulness with which the details of treatment 
are described ; the definite character of the teaching ; 
and last, but not least, the evident candor which 



pervades it, the reader feeling throughout that Dr. 
lhomas is not in the least anxious to conceal his 
own mistakes and failures, or to affect certainty 
where his experience is limited; he would also par- 
ticularize the fulness with which the history of the 
subject is gone into, and which makes the book ad- 
ditionally interesting and gives it value as a work of 
reference. — London Medical Times and Gazette, 
July 30, 188 1. 



SMITH ON CHILDREN.— New Edition. 

A Complete Practical Treatise on the Diseases of Children. By 
J. Lewih Smith, M.D., Clinical Professor of Diseases of Children in the Bellevue 
Hospital .Medical College, New York. Fifth edition, thoroughly revised and re- 
written. In one large and handsome octavo volume of 836 pages, with illustrations. 
Oloth, |4.60 : leather, $5.50; very handsome half Russia, raised bands, $6.00. 

ThtS edition of Dr. .Smith's valuable work has 
received considerable add tions, and some topics are 
discussed in this which have not been treated in the 



preceding editions. The work is thoroughly prac- 
tical in its character, and the treatment is such as 



has been thoroughly tested. There is no better 
book on this subject in the English language than 
this new edition of Dr. Smith's treatise. — St. Louis 
Courier of Medicine , August, 1882. 



PL A YF AIR'S MIDWIFERY.— Third Edition.— Now Ready. 

A Treatise on the Science and Practice of Midwifery. By "W. S. 

I'r.WKAiK. .M.I). F.K.C.P., Professorof Obstetric Medicine in King's College, 

tc. Third American edition, revised by the author. Edited, with additions, 

by Robert 1'. Harris, M.I). In one handsome octavo volume of 659 pages, with 

1-:; illustrations. Cloth, $4.00 ; leather, $5.00 ; very handsome half Russia, $5.50. 

HENRY C\ LEA'S SON & CO., PHILADELPHIA. 



HEX BY C. LEA'S SOX & CO.'S 

(LATE HENRY C. LEA> 

CLASSIFIED CATALOGUE 

O F 

MEDICAL AND SURGICAL 

PUBLICATIONS. 



In asking the attention of the profession to the works advertised in the following pages, 
the publishers would state that no pains are spared to secure a continuance of the confi- 
dence earned for the publications of the house by their careful selection and accuracy and 
finish of execution. 

The large number of inquiries received from the profession for a finer class of binding* than is 
usually placed on medical books has induced us to put certain of our standard publications in 
half Russia ; and, that the growing taste maybe encouraged, the prices have been iked at SO small 
an advance over the cost of sheep as to place it within the means of all to possess a library that 
shall have attractions as v:ell for the eye as for the mind of the reading practitioner. 

The printed prices are those at which books can generally be supplied by booksellers 
throughout the United States, who can readily procure for their customers any works ii"t 
kept in stock. "Where access to bookstores is not convenient, books will be sent by mail 
postpaid on receipt of the price, and as the limit of mailable weight has been removed, HO 
difficulty will be experienced in obtaining through the post-office any work in this cata- 
logue. No risks, however, are assumed either on the money or on the books, and no pub- 
lications but our own are supplied, so that gentlemen will in most cases find it n 
venient to deal with the nearest bookseller. 

A handsomely illustrated catalogue will be sent to any address on receipt of a ; 
stamp. 

HENRY C. LEA'S SON 6 < 0. 

Nos. 706 and 703 Sansom St., Philadelphia, August, 1884. 



PROSPECTUS FOR 1834. 

A WEEKLY MEDICAL JOURNAL. 



SUBSCRIPTION RATES. 

The Medical News Fiv« Dollars, 

The American Journal of the Medical s< nsst bb Fire Dollars. 



COMMUTATION RATES. 
The Medical N \ Nine Doll 

The American Journal of the Medical I annum, In adrsj 

THE MEDICAL NEWS. 

A National Weekly Medical Periodical, containing 28 to :*-' Quarto 
Pages of Beading matter In Bach tone. 

In making the change, over t¥ e,froma monthly 1 

of The Medical News, proposed to furnish the irhat it bad 

enjoyed— a journal national in the m di the word, d< 

of professional morals and honor, an onspari] I quackery and fra 

magazine in elaboration, and a newspaper \l 

even- respect it has fulfilled it- pn mh ; contributor 

State and Territory rial Staff ii 



Henry C. Lea's Son & Co.'s Publications — The Medical News. 



profession, and in every issue living topics are editorially discussed in a scholarly and prac- 
tical manner; its corps of qualified reporters and correspondents covers all the medical 
centres of both hemispheres, and secures for its columns the earliest information on 
matters of medical interest, and its reports of Medical Progress are culled from all the 
important professional journals published on both continents. In short, its unrivaled 
organization enables The News each week to lay upon the table of its readers an epit- 
ome of a week's advance of the whole medical world. 

The News, always endeavoring to enhance its usefulness, has pleasure in announcing to 
the profession that arrangements have been perfected for the publication during this 
year of a highly valuable series of practical articles by eminent men on the more im- 
portant diseases met with by every practitioner in his daily duties. The following gentle- 
men have kindly promised to aid in carrying out this plan, and the eminence of their 
names is a guarantee of the value of the papers to be contributed by them. 



D. HAYES AGNEW, Philadelphia. 
HARRISON ALLEN, Philadelphia. 
I. E. ATKINSON, Baltimore. 
ROBERTS BARTHOLOW, Philadelphia. 
S. M. BEMISS, New Orleans. 
L. DUNCAN BULKLEY, New York. 
CHARLES H. BURNETT, Philadelphia. 
SAMUEL C. BUSEY, Washington. 
WILLIAM H. BYFORD, Chicago. 
P. S. CONNER, Cincinnati. 
J. M. DA COSTA, Philadelphia. 
FREDERIC S. DENNIS, New York. 
FRANK DONALDSON, Baltimore. 
LOUIS A. DUHRING, Philadelphia. 
ROBERT T. EDES, Boston. 
J. FERGUSON, Toronto. 
AUSTIN FLINT, New York. 
WILLIAM GOODELL, Philadelphia. 
SAMUEL D. GROSS, Philadelphia. 
SAMUEL W. GROSS, Philadelphia. 
J. F. HEUSTIS, Mobile, Ala. 
WILLIAM HUNT, Philadelphia. 
JOSEPH C. HUTCHISON, Brooklyn. 
JAMES NEVINS HYDE, Chicago. 
A. REEVES JACKSON, Chicago. 
EDWARD W. JENKS, Chicago. 
A. F. A. KING, Washington. 
GEORGE M. LEFFERTS, New York. 
WILLIAM T. LUSK, New York. 
JOHN M. MACKENZIE, Baltimore. 
HUNTER McGUIRE, Richmond. 



RICHARD McSHERRY, Baltimore. 
THOMAS M. MARKOE, New York. 
S. WEIR MITCHELL, Philadelphia. 
THOMAS G. MORTON, Philadelphia. 
L. S. McMURTRY, Danville, Ky. 
WILLIAM F. NORRIS, Philadelphia. 
WILLIAM OSLER, Montreal. 
FESSENDEN N. OTIS, New York. 
ALONZO B. PALMER, Ann Arbor, Mich. 
ROSWELL PARK, Buffalo. 
THEOPHILUS PARVIN, Philadelphia. 
WILLIAM PEPPER, Philadelphia. 
F. PEYRE PORCHER, Charleston. 
THADDEUS A. REAMY, Cincinnati. 
J. C. REEVE, Dayton, O. 
LEWIS A. SAYRE, New York. 
FRANCIS J. SHEPHERD, Montreal. 
STEPHEN SMITH, New York. 
J. LEWIS SMITH, New York. 
LEWIS A. STIMSON, New York. 
ROBERT W. TAYLOR, New York. 
WILLIAM THOMSON, Philadelphia. 
L. McLANE TIFFANY, Baltimore. 
JAMES TYSON, Philadelphia. 
ELY VAN DE WARKER, Syracuse, N. Y. 
J. COLLINS WARREN, Boston. 
ROBERT F. WEIR, New York. 
JAMES T. WHITTAKER, Cincinnati. 
EDWARD WIGGLESWORTH, Boston. 
E. WILLIAMS, Cincinnati. 
DAVID W. YANDELL, Louisville. 



Original articles from foreign authorities may also be expected, the first of which 
appeared in the issue of January 5th, 1884, on Digital Exploration of the Bladder 
in Obscure Vesical Diseases, with its results, with 7 original illustrations, by Sir 
Hexry Thompson, of London, Surgeon Extraordinary to the King of the Belgians, etc. 
From the high character of the articles already published, a fair conception may be 
formed of the value of the series to every professional man in active practice. 

In typographical appearance, The News of 1884 shows an advance even upon 
the issues of 1882-83, and nothing has been left undone to economize the time and promote 
the comfort of its readers. It appears in a double-columned quarto form, printed by the 
latest improved Hoe speed presses, on handsome paper, from a clear, easily read type, 
specially cast for its use. 

The Medical News employs all the approved methods of modern journalism with 
the intention of rendering itself indispensable to the profession; and, in the anticipation of 
an unprecedented circulation, its subscription has been placed at the exceedingly low rate 
<>f (5 per annum, in advance. At this price it ranks as the cheapest medical periodical 
in this country, and when taken in connection with The American Journal at NINE 
DOLLARS per annum, it is confidently asserted that a larger amount of material of the 
highest class is offered than can be obtained elsewhere, even at a much higher price. 



Henry C. Lea's Son & Co/s Publications — Am. Journ. Mod. SH. 3 

THE AMERICAN JOURNAL of the MEDICAL SCIENCES, 

Edited by I. MINIS HAYS, A. M.. M . P.. 

Is published Quarterly, on the first days of January, April, July 

and October, each Number containing over Three Hundred 

Octavo Pages, fully Illustrated. 

Founded in 1S20, The American Journal entered with 1884 upon its sixty-fifth 
consecutive year of faithful and honorable service to the profession. Being the only 
periodical in the English language capable of presenting elaborate articles— the form in 
which the most important discoveries have always been communicated to the profi 
The American Journal cannot fail to be of the utmost value to physicians who would 
keep themselves au cowant with the medical thought of the day. It may justly claim that 
it numbers among its contributors all the most distinguished members of the pn 
that its history is identified with the advances of medical knowledge, and that its circu- 
lation is co-extensive with the use of the English language. 

During 1S84 The Journal will continue to present those features which have Long 
proved so attractive to its readers. 

The Original Department will consist of elaborate and richly illustrated articles 
from the pens of the most eminent members of the profession in all parts of the country. 

The Review Department will maintain its well-earned reputation lor discernment 
and impartiality, and will contain elaborate reviews of new works and topics of (he day, 
and numerous analytical and bibliographical notices by competent writers. 

Following these comes the Quarterly Summary of Improvements and Dis- 
coveries in the Medical Sciences, which, being a classified and arranged condensation 
of important articles appearing in the chief medical journals of the world, fur 
compact digest of medical progress abroad and at home. 

The subscription price of The American Journal of tut: Medical Sceen< ES has 
never been raised during its long career. It is still sent free < Five hollars 

per annum in advance. 

Taken together, the Journal and News combine the advantages of the elaborate prep- 
aration that can be devoted to a quarterly with the prompt conveyance of intelligence 
by the weekly; while, by special management, duplication of matter is rendered un- 



it will thus be seen that for the very moderate sum of NINE i OLLA BS in advance 
the subscriber will receive free of posts . and a quarterly journal, i 

the latest advances of the medical sciences, and containing an equivalent of more than 4000 
octavo pages, stored with the choicest material, original ai i ; e Furnished 

by the best medical minds of both hen [1 would be impossible to find el 

so large an amount of matter of the same value of 

tfe&~ The safest mode of remit- rawn to 

the order of the undersigned; where these are noi 
tions maybe made at the risk of the publishers by forwarding in 

Henry C. L Philadelphia, 



*** Communications to both I re invited fi n in all parti 

of the countrv. Original articles contributed exclusively to either periodica] arc liberally 

paid for upon publication. When neo M will be fur- 

nished without cost to the author. 

All letters pertaining to the I 
American Journal of the " 
Office-, 1004 Wal ' dladelphia. 

All letters pertaining to the E be -'ddresaed 

exclusively to Hen iWWphia. 



4 Henry C. Lea's Son & Co.'s Publications — Dictionaries. 

DUNGLISON, ROBLJEY, M.I)., 

I.>i'e /Y feasor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Containing 
B concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 

Bygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. A new edition, thoroughly revised, and very greatly modified and 
augmented. By Richard J. Dunglison, M. £>. In one very large and handsome royal 
octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; very handsome 
half Russia, raised bands, $8. 

The object of the author, from the outset, has not been to make the work a mere lexi- 
con or dictionary of terms, but to afford under each word a condensed view of its various 
medical relations, and thus to render the work an epitome of the existing condition of 
medical science. Starting with this view, the immense demand which has existed for the 
work has enabled him, in repeated revisions, to augment its completeness and usefulness, 
until at length it has attained the position of a recognized and standard authority wherever 
the language is spoken. Special pains have been taken in the preparation of the present 
edition to maintain this enviable reputation. The additions to the vocabulary are more 
numerous than in any previous revision, and particular attention has been bestowed on the 
accentuation, Avhich will be found marked on every word. The typographical arrangement 
has been greatly improved, rendering reference much more easy, and every care has been 
taken with the mechanical execution. The volume now contains the matter of at least 
four ordinary octavos. 

A book of which every American ought to be j work has been well known for about lorty years 
proud. When the learned author of the work and needs no words of praise on our part to recom- 
passed away, probably all of us feared lest the book I mend it to the members of the medical, and like- 
should not maintain its place in the advancing wise of the pharmaceutical, profession. The latter 
science whose terms it defines. Fortunately, Dr. especially are in need of a work which gives ready 
Richard J. Dunglison, having assisted his father in and reliable information on thousands of subjects 
the revision of several editions of the work, and j and terms which they are liable to encounter in 
having been, therefore, trained in the methods ! pursuing their daily vocations, but with which the 1 



and imbued with the spirit of the book, has been 
able to edit it as a work of the kind should be 
edited— to carry it on steadily, without jar or inter- 
ruption, along the grooves of thought it has trav- 
elled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and 



cannot be expected to be familiar. The work 
before us fully supplies this want. — American Jour- 
nal of Pharmacy, Feb. 1874. 

Particular care has been devoted to derivation 
and accentuation of terms. With regard to the 
latter, indeed, the present edition may be consid- 



carried through, it is only necessary to state that ered a complete " Pronouncing Dictionary of 
more than six thousand new subjects have been | Medical Science." It is perhaps the most reliable 
added in the present edition.— Philadelphia Medical , wor fc published for the busy practitioner, as it con- 
Times, Jan. 3, 1874. tains information upon everv medical subject, in 
About the first book purchased by the medical I a { . ov l) for r ??dy access and 'with a brevity as ad- 
student is the Medical Dictionary. The lexicon ^^t? 8 :t 1S practical.-Souttern Medical Record, 
explanatory of technical terms is simply a sine qua * etx 1874 - 

rum. In a science so extensive and with such col- A valuable dictionary of the terms employed in 
laterals as medicine, it is as much a necessity also medicine and the allied sciences, and of the rela- 
to the practising phvsician. To meet the wants of tions of the subjects treated under each head. It 
students and most p"hysicians the dictionary must well deserves the authority and popularity it has 
be condensed while comprehensive, and practical i obtained.— British Med. Jour., Oct. 31, 1874. 
while perspicacious. It was because Dunglison's j Few works of this class exhibit a grander monu- 
met these indications that it became at once the ment of patient research and of scientific lore.— 
dictionary of general use wherever medicine was London Lancet, May 13, 1875. 

studied in the English language. In no former Dunglison's Dictionary is incalculably valuable, 
have the alterations and additions been ana - indispensable to everv practitioner of medi- 
so great. The chief terms have been set in black c i ne pharmacist and dentist.— Western Lancet, 
letter, while the derivatives follow in small caps; March 1874 
!E2SS3EZ2£l&&P£SSC mmM - \. Bhithe^meritttatitcert.inlyh.snoriyrf 



-Cincinnati Lancet and Clinic, Jan. 10, 1874. 



in the English language for accuracy and extent of 



As a standard work of reference Dunglison's references.— London Medical Gazette. 



HOBLYN, RICHARD !>., M. JD. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, $1.50; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table— Southern 
Medical and Surgical Journal. 

RODWELL, G. F., F. R. A. 8., F. C. S., 

r on Natural Science at Clifton College, England. 
A Dictionary of Science : Comprising Astronomy, Chemistry, Dynamics, Elec- 
tricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, 
Pneumatics, Sound and Statics. Contributed by J. T. Bottomley, M.A., F.C.S., William 
Crookes, F.R.S., F.C.S., Frederick Guthrie, B.A., Ph. D., R. A. Proctor, B.A., F.R.A.S., 
< r. F. Kodwell, Editor, Charles Tomlinson, F.R.S., F.C.S., and Richard Wornell, M.A., 
I 'receded by an Essay on the History of the Physical Sciences. In one handsome 
octavo volume of 702 pages, with 143 illustrations. Cloth, $5.00. 



Henry C. Leas Son & Co.'s Publications — Compends, Anat. 5 
HARTSHOBXF. HFXRY. A. M.. 31. JD., 

Lately Professor of Hygiene in the University of Pennsylvania. 
A Conspectus of the Medical Sciences; Containing Handbooks od Anatomy, 

Phvsiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
Second edition, thoroughly revised and greatly improved. In one large royal 12mo. 
volume oi 1028 pages. With 477 illustrations. Cloth, 84.2"i ; leather, $5.00. 

The object of this manual is to afford a conven- industry and energy of its able editor.— Boston 
ient work of reference to students during the brief ; Medical and Surgical Journal, Bept S, 1874 
moments at their command while in attendance We can saw with the strictest truth, that it is the 
upon medical lectures. It is a favorable sign that best work of the kind with which we are acquaint/- 
it has been found necessary, in a short space of ; ed. It embodies in a condensed form all recent 
time, to issue a new and carefully revised edition, contributions to practical medicine, and is there- 
The illustrations are very numerous and unusu- | fore useful to every busy practitioner throughout 
ally clear, and each part seems to have received our country, besides being admirablv adapted to 
its due share of attention. We can conceive such the use of students of medicine. The book is 
a work to be useful, not only to students, but to faithfully and ably executed.— Charleston Medica! 
practitioners as well. It reflects credit upon the Journal. April, 1875. 

STUDENTS' SERIES OF MAJSTJALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine 
and Surgery. They will be written by eminent Teachers or Examiners, and will be 
issued in pocket-size 12mo. volumes of 300-540 pages, richly illustrated and at a low price. 
The following volumes may now be announced: Klein's Elements of Histology, Pepper's 
Surgical Pathology, Treves' Surgical Applied Anatomy, Ralfe's Clinical Chemistry, Clarke 
and Lock wood's Dissectors Manual, Power's Human Physiology, and Bruges Mai 
Medica and Therapeutics, (Just ready) ; Robertson's Physiological Physics, Bellamy's 
Operative Surgery, Bell's Comparative Physiology and Anatomy, Gould's Surgical Diagnosis, 
Pepper's Forensic Medicine, and CuknoVs Medical Appli* d Anatomy, (In active preparation 
for early publication.) For separate notices see index on last page. 

SJEBIJES OF CLINICAL 3IAJSUALS. 

In arranging for this Series it has been the design of the publishers to provide the 
profession with a collection of authoritative monographs on important clinical subjects 
in a cheap and portable form. The appended list of authors and titles will give an idea 
of the general plan, and details regarding size and price may be expected at an early 
dav: Hutchinson on Syphilis; Savage on Insanity, including Hysteria; Bryant on 
the Breast; Treves on Intestinal Obstruction ; MoEBiS 5 Diseases of the Kidney; 

Broadbent on the Puke; Butlin on the Tongm : i rwES on > : < Diseas* i oj < 
Lucas od Dist ases of the Un thra ; Marsh on Diseases of the Joints; Pick on Fractun 
Dislocations. For separate notices see ind ex on last page. 

XEILL, JOHJST, M. I)., and SMITH, F. G., M. &., 

to the Penna. Hospital. Prof. oj of Med. in the 

An Analytical Compendium of the Various Branches of Medical 
Science, for the use and examination of Students. A new edition, revised and improved 
In one very large royal 12mo. volume of 974 pages, with 374 woodcuts. ( Hoth, 1 1 j -tmngly 
bound in leather, raised bands, $4.75. 

LVJDLOW, J. L., M. JD., 

', etc 

A Manual of Examinations upon Anatomy, Physiol 
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. I<> which 
is added a Medica] Formulary. Third edition, thoroughly revised, and nded 

and enlarged. In one handsome royal l2mo. volumeof 316 large pages, with 870 illus- 
trations. .25; leather, 

The arrangement of this volume in the form of question and answ< 
daily suitable for the office ex amination of students, and for t hose preparing for graduation- 

WILSON, ERASMUS, F. B. 8. 

A System of Human Anatomy, General and Special. Edited by 
, K , ht \f. | ieral and Surgical Anatomy m the MedicaH oll< . 

Ohio. In one large and handsome octavo volume of 616 pages, with Hfl dlustral 

Cloth, $4.00 j leatl 

SMITH, H. H., M.I>., «»</ HOBJSTEB, \\M. E., M. />.. 

Sm 

An Anatomical Atlas, Ill;;-t: 
large imperial octavo volume 

CLELAXD, JOHN, M. />.. F. B. 8., 

Profet 

A Directory for the Dissection of the Human Body. En one l2mo. 
volume of 17 8 pages. Cloth, $1.25. 



6 



Henry C. Lea's Son & Co.'s Publications — Anatomy. 



ALLEN, HARRISON, M. I)., 

Professor of Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Chapter on Histology. By E. O. Shakespeare, M. P., Ophthalmologist to the 
Philadelphia Hospital. In one large and handsome quarto volume of about 825 double- 
oolumned pages, with 380 illustrations on 109 lithographic plates, many of which are in 
colors, and 241 engravings in the text. In six Sections, each in a portfolio. Section I. 
HistoIiOGY. Section II. Bones and Joints. Section III. Muscles and Fascle. 
Section IV. Arteries, Veins and Lymphatics. Section V. Nervous System. 
Section VI. Organs of Sense, op Digestion and Genito-Urinary Organs. Just 
ready. Price per Section, $3.50. For sale by subscription only. Apply to the Publishers. 
Extract from Introduction. 

It is the design of this book to present the facts of human anatomy in the manner best 
suited to the requirements of the student and the practitioner of medicine. The author 
believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in 
addition to the text descriptive of the subject, a systematic presentation of such anatomical 
faets as can be applied to practice. 

A. book which will be at once accurate in statement and concise in terms ; which will be 
an acceptable expression of the present state of the science of anatomy ; which will exclude 
nothing that can be made applicable to the medical art, and which will thus embrace all 
of surgical importance, while omitting nothing of value to clinical medicine, — would appear 
to have an excuse for existence in a country where most surgeons are general practitioners, 
and where there are few general practitioners who have no interest in surgery. 

Among other matters, the book will be tound to contain an elaborate description of the 
tissues ; an account of the normal development of the body ; a section on the nature and 
varieties of monstrosities ; a section on the method of conducting post-mortem examina- 
tions; and a section on the study of the superficies of the body taken as a guide to the 
position of the deeper structures. These will appear in their appropriate places, duly 
subordinated to the design of presenting a text essentially anatomical. 



It is to be considered a study of applied anatomy 
in its widest sense — a systematic presentation of 
such anatomical facts as can be applied to the 
practice of medicine as well as of surgery. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con- 
sidered a dry subject. The department of Histol- 
ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 
iar with it. The illustrations are made witn great 



care, and are simply superb. There is as much 
of practical application of anatomical points to 
the every-day wants of the medical clinician as 
to those of the operating surgeon. In fact, few 
general practitioners will read the work without a 
feeling of surprised gratification that so many 
points, concerning which they may never have 
thought before are so well presented for their con- 
sideration. It is a work which is destined to be 
the best of its kind in any language. — Medical 
Record, Nov. 25, 1882. 



CLARKE, W. B., F.R. C.S. & LOCJKWOOI), C. B., F.R. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 

The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. Just ready. See Students' Series of 
Many ah, page 5. 

This is a very excellent manual for the use of the 
student who desires to learn anatomy. The meth- 
ods of demonstration seem to us very satisfactory. 
There are many woodcuts which, for the most 



part, are good and instructive. The book is neat 
and convenient. We are glad to recommend it. — 
Boston Medical and Surgical Journal, Jan. 17, 1884. 



TREVES, FREDERICK, F. R. C. S,, 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 
Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illus- 
trations. Limp cloth, red edges, $2.00. Just ready See Students' Series of Manuals, page 5. 



II' has produced a work which will command a 
larger circle of readers than the class for whioh it 
WUB written. This union of a thorough, practical 
acquaintance with these fundamental branches, 



quickened by daily use as a teacher and practi- 
tioner, has enabled our author to prepare a work 
which it would be a most difficult task to excel. — 
The American Practitioner, Feb., 1884. 



CURJSOW, JOHN, M. B., F. R. C. B., 

Professor of Anatomy at King's College, Physician at King's College JL^ ± 

Medical Applied Anatomy. In one pocket-size 12mo. volume. Preparing. 
Sec Students? Series of Marmots, page 5. 

BELLAMY, EBWARB, F. R. C. S., 

Assistcmtr&wrgeon to the Charing-Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Regions of the Human Body, and intended as an Introduction to 
Operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2,25. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
In one royal 12mo. volume of 310 pages, with 220 
woodcuts. Cloth, 81.75. 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and 
modified. In two octavo volumes of 1007 pages, 
with 320 woodcuts. Cloth, $6.00. 



Henry C. Lea's Son & Ca's Publications — Anatomy. 7 

GRAY, HENRY, F. R. S., 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. The I drawings by 1 L V. Carter, M. IX, 
and Dr. Westmacott. The dissections jointly/by the Authob and Dr. Carter, With 
an Introduction on General Anatomy and Development by T. Bolmes, M. A.. Surgeon to 
St. George's Hospital. Edited by T. Pickering Pick. F. U. ('. s.. Surgeon to and Lecturer 

on Anatomy at St. George's Hospital. London, Examiner in Anatomy. Royal College of 
Surgeons of England. A new American from the tenth enlarged ana improved London 
edition. To which is added the second American from the latest English edition of 
Landmabks, Medical axd Surgical, by Luther Bolden, F.RC.8., author of 
"Human Osteology," "A Manual of Dissections," etc. In cue imperial octavo volume 
of 1023 pages, with 564 large and elaborate engravings on wood. Cloth, $6.00; Leather, 
$7.00 : very handsome half Russia, raised bands, $7.50. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application to 
those details to the practice of medicine and surgery. It tints forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size oi nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. They thus form a complete and 
splendid series, which will greatly assist the student in forming a clear idea of Anatomy, 
and will also serve to refresh the memory of those who may find in the exigencies of 

Practice the necessity of recalling the details of the dissecting-room. Combining, 
oes, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive 
and applied Anatomy, the work will be found of great service to all physicians who receive 
students in their offices, relieving both preceptor and pupil of much labor in laying the 
groundwork of a thorough medical education. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Ilolden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rcn<i< 
type and illustration in anatomical study. 

This well-known work comes to us as the latest ' There is probably no work used so universally 
American from the tenth English edition. As its by physicians and medical students as this nne. 
title indicates, it has passed through many hands It is de lence thai th< 

and has received many additions and revisions, in it. [f the present edition is compared with that 
Thework bible of more improvement, issued two ye 

Taking it all in all, its size, manner of make-up, much it has been improved in thai tira< 
its character and illustrations, its general accur- pages have been added to I cially in 

-oription, its practical aim, and its per- those parts that treat of histology, and m 
splcuitv of stvle, it is the Anatomy best adapted to cuts have been introduced and old 1 

the wants of the student and practitioner.— M 
Record, Sept 15, 1883. 1, 1883. 



Also for sale separate — 
HOLHEN, LUTHER, F. R. C. S., 

Surgeon to St. Bartholomew's and the Fou 
Landmarks, Medical and Surgical. Second American from the latest • 
English edition, with additions by W. W. KEEN, M. 1)., P j Anatomy in 

the Pennsylvania Academy of the* Fine Arts, formerly Lecturer on Anatomy In the Phila- 
delphia School of Anatomy, in one handsome 12mo. volume of 1 18 pages. ( lotl 

This little book is all that can be desired within 
• and its contents will be found simply in- 
valuable to the 
they brin^bef ■ 

everv examination of a patient. It is written in k.-TVi./- 

language so clear cat one oil-' 

I> ALTON, JOHN C, M. D., 

Prof i 

The Topographical Anatomy of the Brain. In i quarto 

volume of about 20 photo- 

graphic illustration »rith a like nun.' 

as well as many carefully-executed •.. 

ELLIS, GEORGE VIMli:. 



Demonstrations of Anatomy. Being a Guide to the K 

Human Bodv bv Direction. From the eighth an. htion. In on 

handsome octavo TOlume of 716 pag, -. writh 249 ill 

Ellis' Demonstration - 
Of the English student of anatomy. In j 
through eight editions it has • 

adapted I ' 

?eem that it had almost reached perfection in tin- 



8 Henry C. Lea's Son & Co.'s Publications — Physiology. 



BALTON, JOHN C, M. &., 

Profeator of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
; leather, $6.00; very handsome half Russia, raised bands, $6.50. 

The merits of Professor Dalton's text-book, his more compact form, yet its delightful charm is re- 
smooth and pleasing stylo, the remarkable clear- , tained, and no subject is thrown into obscurity. 
D688 of his descriptions,' which leave not a chapter j Altogether this edition is far in advance of any 
obeoore, hifl cautious judgment and the general j previous one, and will tend to keep the profession 
Correctness of his facts, are perfectly known. They , posted as to the most recent additions to our 
have made his text-book the one most familiar physiological knowledge. — Michigan Medical News, 
to American students.— Med. Record, March 4, 1882. I April, 1S82. 

Certainly no physiological work has ever issued ! One can scarcely open a college catalogue that 



from the press that presented its subject-matter in 
a clearer and more attractive light. Almost every 
page bears evidence of the exhaustive revision 
that has taken place. The material is placed in a 



does not have mention of Dalton's Physiology as 
the recommended text or consultation-book. For 
American students we would unreservedly recom- 
mend Dr. Dalton's work- Va. Med. Monthly, July,'82. 



FOSTER, MICHAEL, M. B., F. R. 8., 

Professor of Physiology in Cambridge University, England. 

Text-Book of Physiology. Second American from the third English edition. 

Edited, with extensive notes and additions, by Edward T. Reichert, M. D., late 

Demonstrator of Experimental Therapeutics in the University of Pennsylvania. In one 

handsome royal 12mo. volume of 999 pages, with 259 illust. Cloth, $3.25 ; leather, $3.75. 

A more compact and scientific work on physiol- eration the late discoveries in physiological chem- 
ogy has never been published, and we believe our- istry and the experiments in localization of Ferrier 
selves not to be mistaken in asserting that it has and others. The arrangement followed is such as 
now been introduced into every medical college to render the whole subject lucid and well con- 
in which the English language is spoken. This nected in its various parts. — Chicago Medical Jour- 
work conforms to the latest researches into zoology nal and Examiner, August, 1882. 
and comparative anatomy, and takes into consid- 



POWER, HENRY, 31. B., F. R. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. In one handsome pocket-size 12mo. volume of 396 pages, 
with 47 illustrations. Cloth, $1.50. Just ready. See Students' Series of Manuals, page 5. 



This little work is deserving of the highest 

?>raise, and we can hardly conceive how the main 
acts of this science could have been more clearly 
or concisely stated. The price of the work is such 



as to place it within the reach of all, while the ex- 
cellence of its text will certainly secure for it most 
favorable commendation. — Cincinnati Lancet and 
Clinic, Feb. 16, 1884. 



DRAPER, JOHN C, 31. B., LL. B., 

Professor of Chemistry in the University of the City of New York. 
Medical Physics. A Text -book for Students and Practitioners of Medicine. In 
one handsome octavo volume of about 600 pages, with about 250 woodcuts. Preparing. 

The object of the author has been to present in a clear and concise manner, without 
undue technicalities, the most modern views of physics in their special bearing on medical 
science. Familiarity -with the laws and principles which govern the relations of force 
and matter is necessary, not only to a clear comprehension of physiology, but is an ines- 
timable aid to the physician and surgeon in their daily practice; yet the subject is 
strangely neglected in professional education and is one for which the medical student 
has do special text-book. This want Professor Draper has endeavored to supply, and his 
distinguished reputation guarantees such a presentation of the subject that the work 
will be one, not only essential to the student, but of interest and importance to the 
intelligent practitioner. 

ROBERTSON, J. McGREGOR, M. A., 31. B., 

Muirhead Demonstrator of Physiology, University of Glasgow. 
Physiological Physics. See Students' Series of Manuals, page 5. Preparing. 

BELL, F. JEFFREY, M. A.~ 

< hmpnrative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In active preparation for early 
publication. See Studentd Series of Manuals, page 5. 

CARPENTER, WM. B., M. B., F. R. S., F. G. S., F. L. S., 

frar to the University of London, etc. 

Principles of Human Physiology. Edited by Henry Power, M.B., Lond., 
F. R. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the 
eighth revised and enlarged edition, with notes and additions by Francis G. Smith, M. D., 
late Professor of the Institutes of Medicine in the University of Pennsylvania. In one 
very large and handsome octavo volume of 1083 pages, with two plates and 373 illus. 
trations Cloth, |5.60; leather, $6.50; half Russia, $7. 



Henry C. Lea's Son & Co.'s Publications— Chemistry. 9 

ATTFIELD. JOHX, Ph. 2>., 

Practical Chemistry to the Pharmaceutical 6 G ■' Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; [ncluding the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 

and their Application to Medicine and Pharmacy. A now American, from the tenth 
English edition, specially revised by the Author. In one handsome royal L2mo. volume 
of 728 _ s, ith 87 illustrations. Cloth, $2.50; Leather, $3 



It is a book on which too much praise cannot be 
bestowed. As a text book for medical schools it 
is unsurpassable in the present state of chemical 
science, and having been prepared with a special 
view towards medicine and pharmacy, it is alike 



indispensable to all i .1 in those de- 

partments of science. It includes the whole 
chemistry of the last Pharmacopoeia.— Pacific .!/• / - 
cat and S ' • , Jan. 1884. 



BLOXA3I, CHARLES L., 

chemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In <>ne very handsome octavo 
volume of 727 pages with '20-J illustration'-. Cloth, $3.75; leather. *4.7-">. Just ready. 



The general plan of this work remains the 
same a* in previous editions, the evident object 
being to giveelear and concise descriptions of all 
known elements and of their most important 
compounds, with explanations of the chemical 



laws and principles involved. We gladly repeat 
now the opinion we mt a former 

edition, that we regard Bloxam's i 
one of the best treatises on general and applied 
chemistry. — America 1 ) J acy, Dec. 1883. 



FRAXKLAXD. E., D.C.L., F.R.S., & J AFP, F. R. 9 F.C.S. 

Inorganic Chemistry. In one handsome volume, with illustrations. Preparing. 



SI3IOX, TV., Ph. F>., 31. F>. 9 

Toxicology in the College of Physicians end Surgeons, Baltimore. 
Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
In one 12mo. vol. of 400 pp.. with 17 woodcuts and ( .» plates of actual deposits. In press. 



RE3ISEX. IRA. M. D., Ph. D., 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
I hemical Compounds. Second and revised edition. In one handsome royal L2mo. 

volume of 240 pages. Cloth, 81.75. Just 

The book is a valuable contribution to the chemi- of chemistry. Tie- high reputation "f the author 
cal literature of instruction. That in so few year- accuracy in all i 

i has been called for indicates that judici 
manv chemical teachers have been found ready bined with I ith jrhich, in 

to endorse its plan and to adopt its methods. In com; 
this edition a considerable proportion of the book towai 

has been rewritten, much new matter has been J it a value much beyond that a I 

added and the whole ;.- - 

We earnestlv commend this book b 



lencan trom me tweiiui ana emttrgeu iahiuuu buuuu. cm«« • 

, M. D. In one large royal 12mo. volume th 177 illustrations 

lored plate. 



FOWXES, GEORGE, Ph. D. 

A Manual of Elementary Chemistry; Theoretical and PracticaL Revised 
rected by Henry Watts, P>. A.. F.R.8.. Editor of A Dictionary of ( he 
Lmerican from the twelfth and enlarged London edition. Edit* 
Bredg - 
on wood and i 
The book opens with a treatise on Chi 

and brieflv, but 

•mprehend t.v 
try proper. It - 

m works on chemistry, but their 

_ 
. reat advance in the - 

Wohler's Outlines of Organic Chemist 
by In i 'I. \y. I'll. D. En one 12mo. volume of 660 pages. ClotJ 

eALLOWAT^QUALITATTVl 

editioi 
LEHM \ 
IOLOGY. 

with 41 illus:. • 



10 Henry C. Lea's Son & Co.'s Publications — Chemistry. 

HOFFMANN, F., A.M., Fh.D., & FOWEB F.B., Fh.£>., 

Public Analyst to the State of Aew York. Prof, of Anal. Chem. Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 



We congratulate the author on the appearance 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



tion of them singularly explicit. Moreover, it is 
exceptionally free from typographical errors. "We 
have no hesitation in recommending it to those 
who are engaged either in the manufacture or the 
testing of medicinal chemicals. — London Pharma- 
ceutical Journal and Transactions, 1883. 



WATTS, HENRY, B. A., F. B. S. 

Author of "A Dictionary of Chemistry" etc. 

A Manual of Physical and Inorganic Chemistry. In one 12mo. volume 
of 500 pages with 150 illustrations. Preparing. 



CLOWES, FBANK, T>. Sc, London, 

Senior Science-Master at the High School, Newcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Second American from the third and revised English edition. 
In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, $2.50. 



The chief object of the author of the present work 
was to furnish one which was sufficiently elemen- 
tary in the description of apparatuses, chemicals, 
modes of experimentation, etc., so as to "reduce' 
to a minimum the amount of assistance required 
from a teacher." It is a generally recognized fact 
that one of the most serious hindrances to the 



renders it unintelligible to the primary student 
unless supplemented by copious verbal explana- 
tions from the teacher. The Elementary Treatise 
of Dr. Clowes, examined with reference to the 
above claims, is found to be a great improvement 
on other elementary works. A student who care- 
fully reads this text will scarcely need the assist- 



utility of many of the smaller text-books is the too j ance of a tutor in following out any of the ex- 
great conciseness of the language employed, which j periments described. — Va. Med. Monthly, Ap., 1881. 



BALFE, CHABLES H., M. L>., F. B. C. F., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 
illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 5. 



This is one of the most instructive little works 
that we have met with in a long time. The author 
is a physician and physiologist, as well as a chem- 
ist, consequently the book is unqualifiedly prac- 
tical, telling the physician just what he ought to 
know, of the applications of chemistry in medi- 



cine. Dr. Ralfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Record, February 2, 1884. 



CHARLES, T. CBANSTOUN, M. D., F. C. S., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 
Handbook for Medical Students and Practitioners. Containing a general account oi 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one octavo volume, 
with 38 woodcuts and 1 colored plate. In press. 



CLASSEN, ALEXANHEB, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
EDOAB F. Smith, Ph. I)., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00. 

and then advancing to the analysis of minerals and 



It is probably the best manual of an elementary 
nature extant, insomuch as its methods are the 
best. It teaches by examples, commencing with 
single determinations, followed by separations, 



such products as are met with in applied chemis- 
try. It is an indispensable book for students in 
chemistry. — Boston Journal of Chemistry, Oct. 1878. 



GBEENE, WILLLAM H., M. L>., 

r of Chemistry in the Medical Department of the University of Pennsylvania. 

A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medicnl ( Ihemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 



It i- n concise manual of three hundred pages, 
giving an excellent summary of the best methods 
of analyzing the liquids and solids of the body, both 
for the estimation of their normal constituents and 



the recognition of compounds due to pathological 
conditions. The detection of poisons is treated 
with sufficient fulness for the purpose of the stu- 
dent or practitioner. — Boston J I. of Chem., June, '80 



Henry C. Lea's Son & Co.'b Publications— Pharm., Mat. Med, 11 



FARRISH. EDWARD. 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia Cvllear of Pharmacy. 

A Treatise on Pharmacy : designed as a Text-book for the Student, ai 
Guide for the Physician and Pharmaceutist With many Formula and Prescriptions, 
Fifth edition, thoroughly revised, by Thomas s. Wibgand, Ph. 6. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5; Leatl 

A new edition of this masterly work, with nu- » valuable guide and compend for the physician 

merous additions, and so revised as to be in accord and medical studen; 

with the new Pharmacopoeia and the latest teach- Apr: 

mgs m chemistry, is a publication of the first im- it would he difficult to find a more complete 
portanoe. No thoroughgoing pharmacist will fail work, for it contains minute information upon 
to possess himself of so usetul aguide to practice, every subject pertaining to pharmacy.— Cincinnati 
and no physician who properly estimates the value Medical Aetrs, Jan. 1884, 
of an accurate knowledge of the remedial agents This well-known work presents itself Q< 
employed by him in daily practice, so far as their upon the recently revised new Pharn i 
miscibihty. compatibility and most effective meth- Several important modifications of the 
ods of combination are concerned, can afford to arrangement have been made, and we believe 
leave this work out of the list of their w< ill be found to increase the practical use- 
reference. The country practitioner, who must fulness of the book. Bach page bears evidence of 
always be in a measure his own pharmacist, will the care bestowed upon it, and conveys valuable 
find it indispensable.— I . information from the rich store of the editor's 
March 2:\ issi. experience. In fact, all that relate 

This treatise on Pharmacy is as indispensable pharmacy— apparatus, 

to the dispensing or manufacturing druggist, and has been arranged and described 

student of pharmacy, as Dung Die- inits various • afford aid and advice 

Uanary is to the doctor and student of medicine, alike to the student and to the practical pharma- 
It has ceased being a literary luxury and I The work is judiciously illustrated ,. 

come a necessity. The work is not merely a text- woodcuts— A merican 

book for pharmacy students and druggists, hut is ary. 



HERMAXX, Dr. L.. 

isor of Physiology in ti Zurich. 

Experimental Pharmacology. A Handbook of Methods for Determini 

Physiological Actions of DniL r s. Translated, with the Author's permission, and with 
extensive additions, by Robert Meade Smith, M. D., Demonstrator ^^ Physiology in the 
University of Pennsylvania. In one handsome 12mo. volume of l ( .)',l pages, with 32 
illustrations. Cloth, $1.50. Ju*t ready. 

Prof. Hermann's handbook, which Dr. Smith has changes produced by poisons, al! an 
translated and enriched with many valuable addi- passed in review in a practical instructive fashion, 
tions. will be gladly welcomed by those engaged in which speaks well for both the author and the 
this department of physiology. It is an excellent translator. The hook is ,;. 

little book, full of concise information, and it mium as a ■ at of the spirit and 

should find a place in every laboratory. It ex- u pharmacoli i 

plains the various methods and instruments used, After closely perusij g 

and points out what lines of investigation are to flowing with the richest facts of physioh _ 
be pursued for studying different phenomena, and after following the astounding 

and also how and what particularly to obse I by the 

.. 1884. author, we fe< tng the 

The selection of animals and their management, realization of that Utopian dream in wl 
the paths of elimination and changes of poisons behold experimental and clinit 
in the body, the explanation of the symptoms pro- firmly and inseparably united. It Is a reliable, 
duced by poisons, alterations in tissue, in the re- for the time- 

productive function and in temperature, action on pressed worker in the la' 
muscles and in nerves, anatomical and chemicai 



JIAISCH, JOHXM., JPhar. />.. 

A Manual of Organic Materia Medica ; I 
the Vegetable and Animal Kingdoms. For the 
and Physicians. New edition, tn one handsome royal 12mo. volui 



BRUXTOX, T. LAUD Eli. M. !>.. 

■ 
A Manual of Materia Medica and Therapeutics, including the Phan 

the Physiological Action and t! 

volutin . 

BRUCE, J. MITCHELL, M. />.. I . R. C. P5 

Materia Medica and Therapeutic 
igea Limp doth. ::. < . J 

GRIFFITH, ROBERT EGLESFIELD, M. />. 

A Universal Formulary, containing the 
tering Officinal and other Medi. ines. The whole adapted to PI 
. bird edition, thoroughly revised, with numerous additi 
Phar.D^Profet nyinthePhiladeli 

Ih one octavo volume of 7 



12 Henry C. Lea's Son & Co.'s Publications — Mat. Med., Therap. 
STILLJE, A., M. D., LL. D., & MAISCS, J. M., Phar.D., 

Professor Sim ritns of the Theory and Prac- Prof, of Mat. Med. and Botany in Phila. 

■ Medicine and of Clinical Medicine College of Pharmacy, Sec' y to the Amen- 

in the University of Pennsylvania. can Pharmaceutical Association. 

The National Dispensatory : Containing the Natural History, Chemistry, Phar- 
macy, Actions and Uses of Medieines, including those recognized in the Pharmacopoeias of 
the "United States, Great Britain and Germany, with numerous references to the French 
Codex. Third edition, thoroughly revised and greatly enlarged. _ In one magnificent 
imperial octavo volume of ahout 1775 pages, with 311 fine engravings. Cloth, $7.25; 
leather. $8.00: half Russia, open back, $9.00. With Dennison's "Ready Reference Index" 
$1.00 in addition to price in any of above styles of binding. Just ready. 

When The National Dispensatory first appeared in 1879 it was hailed as supplying 
a want that had long been felt in both the Medical and Pharmaceutical Professions. Its 
accuracy, its fulness, its conciseness, the happy manner in which, while omitting all that 
was ol»i>lete <>r merely curious, it gave all the information that the practitioner or drug- 
oi >t could desire, not only with regard to the selection, preparation and ^ compounding of 
drugs, but their physiological effects, their therapeutical use and their clinical value, gave 
it at once an unapproached position as a standard work and an indispensable book of 
reference. 

In the present revision the authors have labored incessantly with the view of making 
the third edition an even more complete representative of the science of 1884 than its 
first edition was of that of 1879. For this, ample material has been afforded not only by 
the new United States Pharmacopoeia, but by those of Germany and France, which have 
recently appeared and been incorporated in it, besides a large number of new non-officinal 
remedies. It is thus rendered the representative of the most advanced state of American, 
English, French and German pharmacology and therapeutics. The vast amount of new 
and important material thus introduced may be gathered from the fact that the additions 
to this edition amount in themselves to the matter of an ordinary full-sized octavo volume, 
rendering the work larger by twenty-five per cent, than the last edition. The Therapeu- 
tic Index, so suggestive and convenient to the practitioner, contains 1600 more references 
than the last edition — the general index 3700 more, while the list of illustrations has 
been increased by 80. 

Yet these facts inadequately represent the amount of labor bestowed on the revision, 
for it lias not simply consisted in making additions. The effort has been to prevent 
undue increase of the volume in bulk by having in it nothing that could be regarded 
as superfluous, yet care has been taken that nothing should be omitted which a member 
of either profession could expect to find in it. 

The appearance of the work has been delayed by nearly a year in consequence of the 
determination of the authors that it should attain as near an approach to absolute ac- 
curacy as is humanly possible. With this view an elaborate and laborious series of 
examinations and tests have been made to verify or correct the statements of the Pharma- 
copoeia, and very numerous corrections have been found necessary. It has thus been ren- 
dered indispensable to all who consult the Pharmacopoeia. 

The work is therefore presented in the full expectation that it will maintain the 
position universally accorded to it as the standard authority in all matters pertaining to 
it- subject, as registering the furthest advance of the science of the day, and as embody- 
in- in a >hape for convenient reference the recorded results of human experience in the 
Laboratory, in the dispensing room, and at the bed-side. 

FARQUH ARSON, ROBERT, M. D., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A Guide to Therapeutics and Materia Medica. Third American edition, 
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by 
Frank Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25. 

Dr. Farquharson's Therapeutics is constructed ! umned pages — one side containing the recognized 



upon a plan which brings before the reader all the ! physiological action of the medicine, andthe other 
points with reference to the properties of i the disease in which observers (who are nearly a' 
drills. It impresses these upon him in such a way \ ways mentioned) have obtained from it good n 



a 1 - to enable him to take a clear view of the actions ! suits— make a very good arrangement. The early 
of medieines and the disordered conditions in i chapter containing rules for prescribing is excel- 
which they mud prove useful. The dbuble-col- \ lent.— Canada Med. and Surg. Journal, Dec. 1882. 

STILLJE, ALFRED, M. L>., LL. L>., 

and Praetict of Med. and of Clinical Med. in the Univ. of Penna. 
Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Medicinal Agents, including their Description and History. Fourth edition, 
ad enlarged in two large and handsome octavo volumes, containing 1936 pages. 
( loth, $10.00; Leather, $12.00; very handsome half Russia, raised bands, $13.00. 

We can hardly admit that it has a rival in the j in pharmacodynamics, but as by far the most com- 
multitude of it.- citations and the fulness of its I plete treatise upon the clinical and practical side 
research Into clinical histories, and we must assign ; of the question.— Boston Medical and Surgical Jour- 
it a place in the physician's library; not, indeed, rial, Nov. 5, 1874. 
aa fully representingthe present state of knowledge | 



Henkt C. Leas Son £ Co.'s Publications— Therap., Pathol., Histol. 13 
COATS. JOSEPH. M. &., F. F. P. 8., 

Pathologist to the Glasgow Western Infirmary. 

A Treatise on Pathology. In one von- handsome octavo volume of 829 | 
with 339 beautiful illustrations. Cloth, $6.50; leather, $6.50. Just ready. 

The work before us treat? the subject of Path- condition effected in structures l>y ditt 
ology more extensively than it is usually treated points out the characteristics of 
in similar works. Medical students as well as agencies, so that they can b< 

physicians, who desire a work for study or refer- not limited to morbid anatomy, it explains fully how 
ence, that treats the subjects in the various de- the functions of organs are disturbed by abnormal 
partments in a very thorough manner, but without condit is nothing belonging to its de- 

prolixity, will certainly give this one the prefer- partment of medicine thai - acidated 

ence to any with which we are acquainted. It sets as our present knowledge \.ill admit.— Cincinnati 
forth the most recent discoveries, exhibits, in an Med 
interesting manner, the changes from a normal 



GBEEX. T. HE 3 HI. M. I>.. 

■ on Patholo<; .1 utfomy at Chariag-Crr,$s Hospital M 

Pathology and Morbid Anatomy. Fifth American from the sixth revised 
and enlarged English edition. In one very handsome octavo volume -. with 

150 tine engravings, (loth. $2.50. Just ■ 
The i^sue of the sixth edition of this work indi- and that the authors ardor remains unabated. We 

cates its deservedly sustained popularitvancl value, may confidently recommend it i<> the medical Btu- 
It will )>e a double pleasure to those who have not dent and practitioner as altogether the bes( in our 

forgotten their early debts, to rind that the demand language.— Lancet. .Inly 19, 1884. 

fcrT'r. <--Teen"s manual continues as great as ever. 

WOODHEAD 9 G. SIMS, M. D., F. B. C. P. B., 

Demonstrator of Pathology in the University of Edinburgh. 

Practical Pathology. A Manual for Students and Practitioners, in one very 
beautiful octavo volume of 497 pages, with 136 exquisitelv colored illustrations. Cloth, 
$6.00. Just ready. 

It cannot often be said in these days of literary reagents. We have formed a very high opinion of 

activity, that a book meets a distinct want, that it this work, and we candidly admit that tl 

opens up new ground, and that it is sure to be it little to which exception could possibly 1 

largely in request. All these things are perfectly It is manifestly the product ol « >ne who baa him- 

true of the admirable and handsome volume before self travel led over the whole field and who Is skilled 

us. It is literally the first thorough attempt to deal not merely in the art of histology, but intl 

fully with the subject of practical pathology, es- vatioo ami interpretation of morbid cliaiiL- 

pecially in its histological aspect, and in manner work is .maud a wide circulation. It 

and scope it stands alone. The vast majority of the should do much to encourage the pursuit of path- 
figures interpolated in the text are colored, and - such advantatrr* in his 

colored so as to reproduce with tolerable exactitude have never before been offered.—' 
the appearances of sections stained with vari< 



COBXIL, T., mul BAJSTIEB, L., 

r -. Faculty of Med. oj V 

A Manual of Pathological Histology. Translated, with w>m-> and additions, 
by E. ( ». >h.\ke-peare, M. D.. Pathologist and Ophthalmic Burgeon t<> Philadelphia 
Hospital, and by J. Henry C. Sixes, M. I >.. Demonstrator of Pathological Histology in 
the Universitvof Pennsvlvani;). In one very handsome octavo rolum< 
360 illustration-. Cloth, $5.50; leather, $6.50 : half Russia, raised bands, $7. 

One of the most complete volumes on patholog- Thus side by Bide physio' _ ological 

ical histology we have ever seen. The plan of study anatomy u<> hand la band, affording t) 

embraced w"ithin its paees is essentialiv practical, all proc< in den - »n. The 

Normal tissues are discussed, and after'their thor- admirable arrangement of the work affordfl facility 

ough demonstration we are able to compare any in the study of any part of the human ec 

pathological change which has occurred in them. NewQ 

KLEIN, /;.. M. D., F. B. S.. 

Elements of Histology. In one pocket size 12mo.volum< ith 181 

B. Limp cloth, i ~ ' 

Although an elementary work, it is by no • 
superficial orineonv 

in concise language nearly all the fundamental fa<-t- 
regarding the 



illus. Limp cloth, i . ./ See & 

The ilhi-trn- 



PEPPEE, A. ./.. 31. />'.. M. S.. I . //. C. 8., 

Surgical Pathology. I :!l >] 

illustration-. Limp cloth, n 
Itiapn 

general practitioner. The author i 
admirably in putting the work forward in t: 

f>ractical "form , and he 
ucidity of style and I 

SfHAlERS PRACTICAL Hlfi 
me roval 12mo. volm 
40 ill 
GLUGE^ PATHOLOGICAL Hlfi 



14 Hknry C. Lea's Son k Co.'s Publications — Practice of Med. 
FL1M. AUSTIN, M. !>., 

aetta of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. 7. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. With an Appendix on the Researches 
of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of 
Phthisis. Fifth edition, revised and largely rewritten In one large and closely-printed 
octavo volume of 1160 pages. Cloth, $5.50; leather, £6.50 ; half Russia, $7. Just ready. 

Koch's discovery of the bacillus of tubercle gives promise of being the greatest 
boon ever conferred 1 y science on humanity, surpassing even vaccination in its benefits to 
mankind. In the appendix to his work, Professor Flint deals with the subject from a 
practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog- 

- and treatment of pulmonary phthisis. Thus enlarged and completed, this standard 
work v, ill be more than ever a necessity to the physician who duly appreciates the re- 
ality of his calling. 

A well-known writer and lecturer on medicine This work is so widely known and accepted as 

recently expressed an opinion, in the highest de- the best American text-book of the practice of 

gree complimentary of the admirable treatise of medicine that it would seem hardly worth while to 

Dr. Flint, and in eulogizing it, he described it ac- give this, the fifth edition, anything more than a 

curately as ''readable and reliable."' No text-book passing notice. But even the most cursor y exami- 

is more" calculated to enchain the interest of the nation shows that it is, practically, much more 

Student, and none better classifies the multitudi- than a revised edition; it is, in fact, rather a new 

nous subjects included in it It has already so far work throughout. This treatise will undoubtedly 

won its way in England, that no inconsiderable continue to hold the first place in the estimation 

number of men use it alone in the study of pure , of American physicians and students. No one of 

medicine; and we can say of it that it is in every our medical writers approaches Professor Flint in 

way adapted to serve, not only as a complete guide, clearness of diction, breadth of view, and, what we 

but also as an ample instructor in the science and regard of transcendent importance, rational esti- 

practiee of medicine. The style of Dr. Flint is mate of the value of remedial agents. It is thor- 

always polished and engaging. " The work abounds oughly practical, therefore pre-eminently Vie book 

in perspicuous explanation, and is a most valuable for American readers. — St. Louis Clin. .Sec., Mar. '81. 
text-book of medicine. — London Medical Keus. 



HARTSHOIZXE, HEKRY, M. J}., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth. $2.75 ; half bound, 63.00. 
Within the compass of 600 pages it treats of the this one; and probably not one writer in our day 
history of medicine, general pathology, general had a better opportunity than Dr. Hartshorne for 
symptomatology, and physical diagnosis (including condensing all the views of eminent practitioners 



laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
. Nov. 1S82. 



into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow % 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 



An indispensable book. No work ever exhibited ' disease, and the most valuable treatment. — Chicago 
a better average of actual practical treatment than , Medical Journal and Examiner, April, 1882. 



BRISTOWE, JOHN SYEB, 31. &., F. B. C. JP., 

an and Joint Lecturer on Medicine at St. Thomas' Hospital. 

A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00; leather, $6.00; very handsome half Kussia, raised bands, $6.50. 



The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and 
concise. The additions made by Dr. Hutchinson 



are appropriate and practical, and greatly add to 
its usefulness to American readers. — Buffalo Me-d-. 
ical and Surgical Journal, March, 1880. 



WATSON, SIH THOMAS, M. JD. 9 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
kxe. A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, §11.00. 

LECTURES ON THE STUDY OF FEVER. By LA ROCHE ON YELLOW FEVER, considered in 
A. Hvi>sox, M. D., M. R. I. A. In one octavo its Historical, Pathological, Etiological and 
volume of 308 pages. Clot!.. Therapeutical Relations. In two large and hand- 

3 ON FEVER. Edited by /SvdIToo^ 

John William Moore, M. D., F. K. Q. C P. In A p^ApSJ^K % /HE PRINCIPLES AND 

one octavo volume of 280 pages. Cloth, §2.00. £7^ CI ? CE p£ MEDICINE For the use of 

F 6 Students and Practitioners. By Fkank Wood- 

A TREATISE ON FEVER. By Robert D. Lyons, btjby, M.D. In one roval 12mo. volume, with 

K. C C In one 8vo. vol. of 354 pp. Cloth, $2. 25. I illustrations. Preparing. 

A CENTURY OF AMERICAN MEDICINE, 1776— 1876. Bv Drs. E. H. Clakke, H. J. 
Billow, S. D. Osoaa, T. S. ThomaS, and J. S. Billings. In one 12mo. volume of 370 pages. Cloth, $2.25. 



Henry C. Lea's Sox & Co.'s Publications— Practice of Med. 15 



For Sale bt/ Subscription Only* 



THE 

AMERICAN SYSTEM OF PRACTICAL MEDICINE. 

Edited by WILLIAM PEPPER, M. D., LL. D., 

PROYOST AND PROFESSOR OF THE THEORY AND PRACTICE OF BtEDICTNE AND OF 

CLINICAL MEDICINE IN THE UNIVERSITY OF l'KNNSYI.V AN ! \. 

In five imperial octavo volumes, containing about 1000 pages each, with illustrations. 
Volume I., now in 



The publishers feel pardonable pride in announcing this magnificent work. For 
three years it has been in active preparation, and it is now in a sufficient state of forward- 
ness to justify them in calling the attention oi the profession to it as the work in which 
for the first time American medicine will he thoroughly represented by ii- worthiest 
teachers, and presented in the full development of the practical utility which is its 
preeminent characteristic. The most able men — from t lie East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities of study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that each author ha- had 
assigned to him the subject which he is peculiarly fitted to discuss and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete and nnfa.il ing work of reference, 
to which he may at all times turn with full certainty of finding what he needs in its most 
recent aspect, whether he seeks information on the general principles of medicine, or 
minute guidance in the treatment of special disease. So wide i> the scope of the work 
that, with the exception of midwifery and matters strictly surgical, it embrace- the whole 
domain of medicine, including the department- for which the physician is accustomed to 
rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary Bcience, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Mjedicdte, and the general practitioner pose 
may feel secure that he will require little else in the daily round of professional duties. 

Although every effort has been made to avoid the introduction of matters purely 
speculative, and to condense, as far as possible, the vast amount of practical information 
furnished, yet the accumulation of indispensable material has been such that it hasnot 
been practicable to present it in less than live splendid imj volumes, containing 

about 5000 beautifully printed pages, and embodying the matter of about tilt. -en ordinary 

b illustrations as -erve really to elucidate the subject have been into 
but the editor has done this with a sparing hand, feeling that space might be o 
more usefully and worthily than by superfine 

As a work of which every American physician may reasonably feel proud, and in 
which every practitioner will find a safe and trustworthy counsellor in the daily ri 
hilities of practice, the publishers confidently anticipate a circulation unexampled in the 
annals of medical literature. 

The material for the work is substantially oomph te in the bands of the editor, and a- 
t he prr T with the accuracy indispensable in a 

work of this nature . Bion may look for the first volume in the fall, and for the 

. tent volumes at reasonable intervals therea 

tailed prospectus of the work will be mailed to any address on application to the 


REYNOLDS, J. UTJSSELL, M. />.. 

/- or • /■ P 

A System of Medicine. With notes and additi 
A. M., 11 I).. late Profess >rof Hygiene in the University of !'< nnsj I rania in tin 
and hai 

per volume, cl - k ; 1,:,n ' 1 *. 

Per set, dot • If Kuaria, I 

medical work which 

uently and fully <■■ 
when perplexed by do 
having unusual or apparently 
toms presented to us. than " 

Medicine." It contain." just that kind of informa- 
tion which the busy practitioner : 
himself in need of." In order that a:. 



16 Henry C. Lea's Son & Co.'s Publications — Clinical Med., etc. 
FOTHERGILL, J. M., M. D., Edin., M. M. C. F., Lond., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peut ies. Second edition, revised and enlarged. In one very handsome octavo volume of 651 
pages. Cloth, $400 ; very handsome half Russia, raised bands, $5.50. 



The junior members of the profession will find j of physiology. Every chapter, every line, has the 

— ss of -a master-ha- J 
ighly scientific in ( 
selection and combination of therapeutical agents j to the thoughtful reader all the charms' and beau- 



it a work that should not only be read but care- j impress of -a master-hand; and while the work is 
fully studied. It will assist them in the proper | thoroughly scientific in every particular, it presents 



best adapted to each case and condition, and 
enable them to prescribe intelligently and success- 
fully.— >'. Louis Courier of Medicine, Nov. 1880. 

The author merits the thanks of every well-edu- 
cated physician for his efforts toward rationalizing 
the treatment of diseases upon the scientific basis 



ties of a well-written novel. No physician can 
well afford to be without this valuble work, for its 
originality makes it fill a niche in medical litera- 
ture hitherto vacant. — Nashville JoUm. of Med. and 
Surg., Oct. 1880. 



FLIJST, AUSTIN, M. D. 

Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of 
Diseases. Designed for Students and Practitioners of Medicine. In one large and hand- 
some octavo volume of 799 pages. Cloth, $4.50; leather, $5.50 ; half Russia, $6.00. 

It is here that the skill and learning of the great sistently with Drevity and clearness, the different 

clinician are displayed. He has given us a store- subjects and their several parts receiving the 

house of medical knowledge, excellent for the stu- attention which, relatively to their importance, 

dent, convenient for the practitioner, the result of medical opinion claims for them, is still more diffi- 

a long life of the most faithful clinical work, col- cult. This task, we feel bound to say, has been 

lectea by an energy as vigilant and systematic as executed with more than partial success by Dr. 

untiring, and weighed by a judgment no less clear Flint, whose name is already familiar to students 

than his observation is close. — Archives of Medicine, of advanced medicine in this country as that of 

Dec. 1879. the author of two works of great merit on special 

To give an adequate and useful conspectus of the subjects, and of numerous papers exhibiting much 

extensive field ofmodern clinical medicine is a task originality and extensive research.— The Dublin 

of no ordinary difficulty; but to accomplish this con- Journal, Dec. 1879. 

By the Same Author. 
Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

BBOADBEJSTT, W. S., M. D., F. F. C. F., 

Physician to and Lecturer on Medicine at St. Mary's Hospital. 
The Pulse. In one 12mo. volume. See Series of Clinical Manuals, page 5. 



SCHFEIBEF, I>IZ. JOSEFS. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of about 300 pages, with about 125 fine engravings. Preparing. 

FIJSTLAYSON, JAMES, M. &., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 
Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine. 
With Chapters by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephens on 

« of the Female Organs; Dr. Kobertson on Insanity; Dr. Gemmell on Physical 
I dagnosis ; I )r. ( oats on Laryngoscopy and Post-Mortem Examinations, and by the Editor 
"ii ( .i-e-taking, Family History and Symptoms of Disorder in the Various Systems. In 
one handsome 12mo." volume of 546 pages, with 85 illustrations. Cloth, $2.63. 

- one of the really useful books. It is at- ] bulkier volumes; and because of its arrangement 

■ in preface to the final page, and ought j and complete index it is unusually convenient for 

to be given a place on every office table, because it j quick reference in any emergency that may come 

contains in a condensed form all that is valuable , upon the busy practitioner. — N. C. Med. Journ., 

in semeiology and diagnostics to be found in | Jan. 1879. 



FEJSWICK, SAMUEL, M. I)., 

font Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
>7 illustrations on wood. Cloth, §2.25. 



TAXXEF, THOMAS HAWKES, M. F>. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Kevised and enlarged by Tilbury Fox, M. D., Phy- 
sician to the Skin department in University College Hospital, London, etc. In one small 
lJiuo. volume of 362 pages, with illustrations. Cloth, $1.50. 

8TURGES' INTRODUCTION TO THE STUDY I IMPORTANT DISEASES ; being a collection of 

OF CLINICAL MEDICINE. Being a Guide to the Clinical Lectures delivered in the Medical 

the Investigation of Disease. In one handsome Ward of Mercy Hospital, Chicago. Edited by 

12mo. volume of 127 pages. Cloth, 81.25. Frank H. Davis, M. D. Second edition. In one 

[•AVIS' CLINICAL LECTURES ON VARIOUS ! royal 12mo. volume of 287 pages. Cloth, $1.75. 



Henry C. Leas Son & Co.'a Publications— Hygiene, Eteetr., Praet. 17 
RLCHARDSOl, B. 71.. M.A., JL.JD., LL. L>., F.R.S., F.S.A. 

Fellow of the R f Physicians, L 

Preventive Medicine. In one octavo volume of 729 pages, cloth, $4; leather, 
8-3: very handsome half Russia, raised bands, %L 

Excerpt from Contents. 

I. — Disease as a Unity, with a variety of Phenomena. The Preventive Sch< 
Medicine. General Diseases of Mankind. 1. Constitutional Diseases, 2. LocaJ Diseases. 
3. Diseases from Natural Accidents, — Lightning — Sunstroke — Starvation— Poisons- 
Venoms — Poisonous Food — Pregnancy. 1L Acquired Diseases ol Artificial I 
Phenomena and Course. 1. Acquired Diseases from [norganic and Organic Poisons, — 
Tea — Coffee — Alcohol — Tobacco — Soot— Gases. 2. Acquired Diseases from Physical 
Agencies, Mechanical and General. — Dusl — Pressure en Lungs— Concussions and Shocks 
— Muscular Overwork and Strain — Acquired Deformities — Physical Injuries — Surgical 
Operations. 3. Acquired Diseases from Mental Agencies,— Moral, Emotional and 
Habitual. Diseases from Mental Shock, from Moral Contagion, — Tarantism— Suicide, 
from Hysterical Emotion, from Passion, from Habits of Lire — Insomnia — Dementia — 
Sloth — Luxury — Secret Immorality. 111. — 1. Origins and ( ausesof Disease,— -Congenital, 
Hereditary or Constitutional Causes : Atmospheric and Climatic Causes; Parasitic ' 
— Bacteria — Bacilli — Spirilla — Trichinae; Zymotic Causes: Industrial and Accidental 
Causes: Social and Psychical Causes: Senile Degenerative Causes. 2. Preventions of 
Disease. Prevention of Hereditary or Constitutional Diseases, — Personal Rules for Preg- 
nancy, Infancy, Adolescence. Maturity; Preventionof Atmospheric and Climatic I ' 
of Parasitic Diseases. — Personal Hides; of Zymotic Disea»e<. — Contagion — Drainage — 
Isolation oi Sick — Water and Milk Supply — Hospital- — Registration — Vaccination — 
Other Inoculations — Legislation: Prevention of Industrial Diseases — Lead Poisoning — 
Dusts — Gases, etc.; Prevention of Social and Psychical Diseases, — Warming and Ventila- 
tion — Light — Water — the Bed-room — Bread — Abattoirs — Schools — Sepulturi — I >ruuken- 
ness ; Prevention of Senile Disease. 

Dr. Richardson has succeeded in producing a the question of disease is comprehensive, 
work which is elevated in conception, comprehen- and fully abreast with the latest and best kn<>wl- 
sive in scope, scientific in character, systematic in edge >»n"the subject, and the preventive measures 
arrangement, and which is written in"a clear, con- advised are a [eft and relial 

cise and pleasant manner. He evinces the happy 

faculty of extracting the pith of what is known on This is a book that will surely fin 1 
the subject, and of presenting it in a most simple, table of every prog r '> the 

intelligent and practical form. There is perhaps medical prof - much to 

no similar work written for the general public prevent as to cure disease, the book will b< 
that contains such acomplete. reliable and instruc- 
tive collection of data upon the diseases common The treatise contains a vast amoui 
totherace, their origins, causes, and the measures able hygienic information. — M 
for their prevention. The description* i : rter, Feb. 23, 186 I. 

are clear, chaste and scholarly ; the discussion of 

BARTHOLOW, ROBERTS. A. M., M. 2>., LL. /).. 

■'. of Materia Mediea a a in the JejTer- 

Medical Electricity. A Practical Treatise on the Applications of Electricity 

'cine and Surgery. Second edition. In one Tery handsome octavo volumi 

.vith 109 illustrations. Cloth. | - 

The second edition of this work following so A most excellent work, i 

soon upon the first would in itself appear to be a tioner to his fellow-practitioners, an<] I 

sufficient announcement; nevertheless, the text thoroughly practical, rhe 
ha=> been so considerably r. 

inch enlarged by the additi 
ter, that we cannot fail I 

ment upon the former work. 'The author has pre- the practition 

pared his work for student- and practitioner— for telligently tl 

never acquainted themselves witi. f, and for it* 

I that after a practi. 

time their k. We think sents 



he has accomplished this object. The book is not 
uninoru*, but i" thoi 

over, replete with numerous illustral 
ments, applia. 



dngawh 






HABLRSJIOX. S. <>.. M. />.. 

On the Diseases of the Abdomen: I 

other parts of the Aliment 

American from third enla j , " , »- In " ! 

volume •'' Ulnstrati< 

PAVTO TREATISE 0» THE PUN 

Fro: 
volur:. 

CHAMBERS' MANUAL OF 1 

IN HEALTH AN1 

some octavo volume of 3 - 



1 







18 Henry (J. Lea's Son & Co.'s Publications — Throat, Lungs, Heart. 



COHFX, J. SOLIS, 31 Z>., 

Lcct n rt-r on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of A Sections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, Avith a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 

SFILFB, CAUL, M. I)., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume 
of 294 pages, with 77 illustrations. Cloth, $1.75. 

Dr. Seiler's book is a clear, concise, practical 
exposition of the subject, such as only a master of 
it could have written. It is better suited to the 
wants of advanced students and young physicians 
than any other at present in the hands of the pro- 



sion. — American Practitioner, Aug, 1883. 



Dr. Seiler's treatise contains all the essentials of 
the knowledge of the important localities com- 
pressed into a small space and put together by 
one of the ablest of American specialists. To stu- 
dents and others this book can be recommended 
as one of the best and most generally useful. — 
Canada Medical and Surgical Journal, July, 1883. 



BROWNE, LENNOX, F. B. C. S., Fdin., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 
The Throat and its Diseases. Second American from the second English edi- 
tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, 
designed and executed by the Author. In one very handsome imperial octavo volume of 
about 350 pages. Preparing. 

FLINT, AUSTIN, M. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. 

A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand- 
some royal 12mo. volume of 240 pages. Cloth, $1.63; Just ready. 

This practical and justly popular manual is con- the author's plan is to simplify the subject i 
veniently divided into eight chapters, and the 
student is gradually led up from a general con- 
sideration of physical signs in health and disease 
to the differential diagnosis of diseased conditions 
by a knowledge of these physical signs. As in his 
courses of practical instruction, so in this book 



much as possible; to impress the fact that 
close study of the physical conditions in health 
and disease is a sine qua non of success in both 
diagnosis and treatment. — The Medical News, 
April 28, 1883. 



BY THE SAME AUTHOR. 

Physical Exploration of the Lungs by Means of Auscultation and 
Percussion. Three lectures delivered before the Philadelphia County Medical Society, 
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. 

A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. 
Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

I) ALTON, JOHN C, M. JD., 

Professor of Physiology and Hygiene in the College of Physicians and Surgeons, New York. 

Doctrines of the Circulation of the Blood. In one handsome 12mo. 
volume of 150 pages. In press. 

GROSS, S. D., M.L>., LL.JD., D.C.L. Oxon., LL.JD. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 
octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one 12mo. vol., pp. 158. Cloth, $1.25. 

WAL8HB ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 



SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. 8vo., pp. 253. $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 

CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS, by C. Handfield Jones, 
M. D. Second American edition. In one hand- 
some octavo volume of 340 pages. Cloth, $3.25. 



Henry C. Lea's Sox & Co.'s Publications— Nerv. and Ment. Dis.,etc. L8 
HAMILTON, ALLAH JIcLAXE. M /).. 

Attending Physician at the Hospital for Epileptics and Paralytics, BlacbMtPt Iakmd\ N. V. 
Nervous Diseases ; Their Description and Treatment Second edition, thoroughly 

revised and rewritten. In one octavo volume of 598 pages, with 72 Illustrations. ( loth, $4, 
When the first edition of this good book appeared characterized this book as the beal of Its kind in 
we gave it our emphatic endorsement and the any language, which is a handsome end< 

E resent edition enhances our appreciation of the from an'exulted source. The improvements in the 
ook and its author as a safe guide to students ol new edition, and the additions to it, will lustlfy its 
clinical neurology. One of the best and most purohase oven by those who possess the Old.— 
critical of English neurological journals, Brain, has Alienist and Nt ril, 1882. 

TTJKE, DAXIEL HACK. M. IX. 

Joint Author of The Manual of Psychological Medicine, etc. 
Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action oi the Imagination. New edition, 
Thoroughly revised and rewritten. In one handsome octavo volumi jes, with 

two colored plates. Cloth, $3.00. Just read;/. 

* * * These few extracts from Dr. Tuke's book The bibliography and general index at the end ol 

give an idea in a limited manner of the interesting thebookareexeelloi 

matters there discussed. They fail, how.". . May 1. 1884. 

give even a faint idea of the strength of treatment, It is really one of those books that n< . 

the rich coloring and clearness and skill of style old. The more it is read, the more it wid be an- 

with which every subject is elaborated. As physi- predated. Difficult and arduous as is the hand- 

cians we should constantly bear in mind the iin- ling of so wide and important a BUbject in its 

portance of the expectant treatment of disease, varied aspects, the distinguished author has most 

We probably all suppose that we know almost effectually succeeded in placing upon a firm and 

everything 'about this treatment now, but Dr. rational basis, the complex phenomena resulting 

Tuke's book, which we all should own and read, from the infln I iind upon the body.— 

will make the modest among us hang our heads. \ Southern Practitio I 



CLOLSTOJT, THOMAS 8., 31. I)., F. R. C. T., L. B. ( . S. $ 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 

Abstract of the Statutes of the United States and of the Several StateB and Territories re- 
lating to the Custody of the Insane. By CHARLES F. FoiSOM, M. D., Assistant Pi 

of Mental Diseases', Medical Department of Harvard University. In one handsome 
octavo volume of 541 pages, illustrated with eight Lithographic plates, four of which 
are beautifully colored. Cloth, $4. Just ready. 

Dr. Cloustoms book is one long record of accu- I disposal in this interesting volume Repeatedl) 
rate and laborious observation. From cover to at frequent intervals the results of Dr. I 
cover the book is positively bursting with facts, ripe experience are put before US in 
It presents to the student of alienism an almost of empirical generalizations, which, representing 
embarrassing profusion of data. The number of multitudinous observation-. :, itolarge 

cases which are recorded in full is considerable, groups of facts. Nor Is this all, for in addition to 
and the skill with which the salient points of each the excellent therapeutics with which th< 
case have been chosen for presentation, and the saturated, we meet with many shrewd 
graphic terseness with which thev are described, and occasionally with a Bash of true philosophic 
will be fully appreciated. The re- insight.— Brain? April, 1884. 

are far from' being the only materials placed at our 

Also in, separate form — 
FOLSOJI, CHARLES F., 31. D. 9 

cm t Professor ■ 
An Abstract of the Statutes of the United States, 
States and Territories relating to the Custody of th<- [nsane. In one 8vo* volume of LOB 

■ 

SAVAGE, GEORGE H., M. Z>., 

Insanity, including Hysteria. In "no L2mo. volume, Preparin 



PLAYFAIR, W. S., V. I>., F. R. C. !>.. 

The Systematic Treatment of Nerve Pros: 
one handsome small 12mo. volume oi Cloth, $1.00. J 

to Wh 

■ 



The book is well worth perusal, and will repay 
anyone for the time spent in it^ careful b! 
asrnueh as it will lead to a tx I 
the management of I 

cian, nerve prostration and hysteria. I" 
given of the manner of carry 



MFTCHELL, S. WE lit. V. />.. 

Lectures on Diseases of the Ncrvo.* 
Second edition. In one very i andaome I2ma rd 

Blandford on Insanity and its Treat. 

Medical and Legal, of In.- I 



20 



Henry C. Lea's Son & Co.'s Publications — Surgery. 



GROSS, S. D., M. D., LL. D., D. C. L. Oxon., LL. D. 
Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System, of Surgery : Pathological, Diagnostic, Therapeutic and Operative. 
Six tli edition, thoroughly revised and greatly improved. In two large and beautifully - 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15; half Kussia, raised bands, $16. 

His ,,'., which, since its first edi- I and, above all, has conscientiously adhered to 

tion In 1869, has been a standard work in this i truth and fact, weighing the evidence, pro and 
country as well as in America, in "the whole con, accordingly. A considerable amount of new 
domain of surgery," tells how earnest and labori- j material has been introduced, and altogether the 
ous and wise a surgeon he was, how thoroughly distinguished author has reason to be satisfied 
he appreciated the work done by men in other that he has placed the work fully abreast of the 
countries, and how much he contributed to pro- | state of our knowledge. — Med. Record, Nov. 18, 1882. 
mote the science and practice of surgery in his ' We regard Gross' System of Surgerv not only as 
There has been no man to whom America i a singularly rich storehouse of scientific informa- 

? received 
,.-■«, ~f the emi- 
Btandard work on that subject for students and nen t author himself, assisted in various instances 
practitioners. — London Lancet, May 10, 1S84. 

The work as a whole needs no commendation. 
Many years ago it earned for itself the enviable rep- 
utation of the leading American work on surges, 
and it is still capable of maintaining that standard. 
The reason for this need only be mentioned to be 
appreciated. The author has always been calm 



km ii. nieie iuis ueen nu ihhu w h num /iinciiua, i a gineuiariy ncn storenouse oi scientmc miorn 
l- BO much indebted in this respect as the Nestor tion, "but as marking an epoch in the literary h 
of eureery.— British Medical Journal, May 10, 1884. j torv of surgerv. The present edition has receiv 
Dn Gross' System of Surgery has longbeen the | the most careful revision at the hands of the en 

nent author himself, assisted in various instanc 
by able specialists in various branches. All depart- 
ments of the vast and ever-increasing literature of 
the science have been drawn upon for their most 
recent expressions. The late advances made in 
surgical practice have been carefully noted, such 
as the recent developments of Listerism and the 
improvements in gynaecological operations. In 
and judicious in his statements, has based his con- j every respect the work reflects lasting credit on 
elusions on much study and personal experience, | American medical literature. — Medical and Surgical 
' * been able to grasp his subject in its entirety, j Reporter. Nov. 11, 1882. 



ASHHTJRST, JOHN, Jr., M. D., 

Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. 

The Principles and Practice of Surgery. Third edition, enlarged and re- 
vised. In one large and handsome octavo volume of 1060 pages, with 555 illustrations, 
Cloth, $6 ; leather, $7 ; very handsome half Russia, raised bands, $7.50. 

Dr. Ashhurst's Surgery is a condensed treatise 
covering the whole domain of the science in one 
manageable volume. The present edition has had 



i thorough revision. The novelties in surgical 
practice and the recent observations in surgical 
science have been incorporated, but the size of the 
volume has not been materially increased. The 
author's arrangement is perspicuous, and his 
language correct and clear. An excellent index 
closes the work.-J/ed. and Surg. Reporter, Oct. 28/82. 
The author, long known as a thorough student 
of surgery, and one of the most accomplished 
scholars in the country, aims to give in this work 
"a condensed but comprehensive description of 
the modes of practice now generally employed in 
the treatment of surgical affections, with a plain 
exposition of the principles upon which these 
modes of practice are based." In this he has so 
well succeeded that it will be a surprise to the 
reader to know how much practical knowledge ex- I ceived. 
tending over such a wide range of research is com- | the wor 



pressed in a volume of this size. This feature of 
the work must be its best claim for continued 
popularity with students and practitioners. In 
fact, in this respect it is without an equal in any 
language. In the present edition many novelties 
in surgical practice are introduced, many modifi- 
cations of previous statements made, and several 
new illustrations added.— Med. Rec, Nov. 18, 1882. 
It treats in a very thorough and satisfactory 
manner all the subjects in the various departments 
of surgery. The medical student and general prac- 
titioner of medicine will find it admirably adapted 
to their wants, the former as a text-book, and the 
latter as a most valuable work of reference when 
he wishes to refresh his mind and obtain the latest 
information on any subject of surgery. In revising 
his work for a third edition, the author has spared 
no pains to render it worthy of a continuance of 
the favor with which it has heretofore been re- 
We predict an increasing demand for 
Cincinnati Medical News, Nov., 1882. 



GIBNEY, V. JP., M. D. 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopaedic Surgery. For the use of Practitioners and Students. In one hand- 
some octavo volume, profusely illustrated. Preparing. 

ROBERTS, JOHN B., A. M., M. D., 

L> cturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. 

The Principles and Practice of Surgery. For the use of Students and 
Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 
with many illustrations. Preparing. 



BELLAMY, EDWARD, F. R. C. S. 

Operative Surgery. In active preparation. See Students' Series of Manuals, page 5. 

, M. V., 

of New York, Surgeon and Curator to Bellevue Hosp. 
In one verv handsome royal 12mo. volume 
!.50. 



STIMSOJST, LEWIS A., B. A 

Prof, of Pathol. Anat. at the Univ. of the City 

A Manual of Operative Surgery. 
of -177 pages, with 332 illustrations. Cloth, $! 
Thifl volume is devoted entirely to operative sur- | 
tid is intended to familiarize the student i 
with the details of operations and the different 
modes of performing them. The work is hand- 
somely illustrated, and the descriptions are clear 
and well-drawn. It is a clever and useful volume ; I 



every student should possess one. This work 
does away with the necessity of pondering over 
larger works on surgery for descriptions of opera- 
tions, as it presents in a nutshell what is wanted 
by the surgeon without an elaborate search to 
find it. — Maryland, Medical Journal, August, 1878. 



Henry C. Leas Son & Da's Publications — Surgery. 



21 



BBTAXT. THOJIAS, F. B. C. 8., 

Surgeon a : I Let - ion. 

The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of over 1" 
with about 750 illustrations. 

A notice of the previous edition is appended. 
It is a work especially adapted to the wants of sent the student with practical information, and 
students and practitioners. It affords instruction that alone, than to burden his memory with the 
in sufficient detail for a full understanding of >ur- views of different \\ distinguished 

gical principles and the treatment of surgical dis- they might have been. In this edition tl 
eases. It embraces in its scope all the diseases work has been earefullv revised, much of it has 
that are recognized as belonging to surgery, and been rewritten, and Important additional 
all traumatic injuries. In discussing these it has made to almost every chapter. — GEnewuuri 
seemed to be the aim of the author rather to pre- News, Jan. 188L 

EBICHSEX, JOH3E.. F. B. S., F. B. C. 8., 

. London, etc. 

The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Ms- 
eases and Operations. From the eighth and enlarged En.iili-h edition. In two large and 
beautiful octavo volumes of about 2000 pages, illustrated with about 900 engrai 
wood. In 

ES3IABCH. Dr. FBIEDBICH, 

■ i -?• of Surgery at the University of K 

Early Aid in Injuries and Accidents. Five Ambulance Lect 
lated by H. E. H. PKrxcEss Christian. In one handsome small 12mo. volume of 1<>9 

pages, with 2-4 illustrations. Cloth. 75 cents. Ju& 

The excellent little handbook by T>v. Esmarch organization of the human' body, lllual 
may be referred to by all for clear, safe and practi- clear, suitable diagrams. The second t<-.. 
cal'directions and instructions for rendering the to give judicious help in ordinary injuries — oonto- 
right kind of aid until the doctor arrives, in the sions, wounds, haemorrhage and poisoned wounds. 
event of the numerous injuries that are liable to The third treat* of first aid in cases " - 
happen in a family or neighborhood in the circum- and of dislocations, in sprains and in bur: - 
stances of daily" life. The manual is earnestly the methods of affording first treatment in cases 
andjustly commended for its excellence and clear- 
ness, and especially for the minuteness and extent - snese isoning are dec 
of its practical details. — Harp .'.' . Aug., and the fifth lectur. 

1883. may be m<>~r Bafely and easily transported t.. their 

,rse of instruction is divided into five medical man. or to a hospital. The 

- or lectures. The first, or introductory illustrations in the book are clear and g i.— .V"»<- 

lecture, gives a brief account of the structure and m 



BBYAXT, THOMAS, F. B. C. v. 

a to and Led* 

Diseases of the Breast. In one 12mo. volume. /' S ' 

_e 5. 

TBEVES, FEEDEBICK, F. B. C. 8., 

- 
Intestinal Obstruction. In one 12mo. volume. /' See& Clinical 



BVTLIX, HEXBY T., F. B. C. s.. 

Diseases of the Tongue. In one l2mo. volume 



GOVLIJ. A. PEABi E, M. 8., M. B. f /. R. C. 8., 

Surgical Diagnosis. A Manual for the Warda. In • • l2mo. rol- 

ume. / See 5 



DEIITT, BOBEBT. M. //. C. 8., <tc 



London 



The Principles and Practice of Modern Surgery. 1 
Ion edition. Ln one 8vo. volun* Mus. Cloth, \ 



From th( 



BAROENTON1 

- "F MINOR SURGERY, 
with a Chapter on military 

volur: 
MILLER'S PRINCIP1 

American from the third Edinburgh edit, 
. vol. of 688 pages, with 340 illu"tr 

Cloth. 
MILLERS PRACTICE OF SURGERY. ' 

and revised American from the la 

edition. In one larg< 

364 illustrations. Cloth, 5 ~ '" I ••-•'-.■••'•■■» I 






ERY. Il 



11 Uknrv 0. Lea's Son & Co.'s Publications — Surgery. 

HOLMES, TIMOTHY, M. A., 

on and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TREATISES BY 
VAKIOUS AUTHOBS. American edition, thoroughly revised and re-edited 
by John II. Packard, M. IX, Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons* 
En three Large and very handsome imperial octavo volumes containing 3137 double- 
oolumned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully 
colored. Price per volume, cloth, $6.00 ; leather, $7.00 ; half Russia, $7.50. Per set, cloth,. 
$18.00 ; leather, $21.00 ; half Russia, $22.50. Sold only by subscription. 

Volume i. contains General Pathology, Morbid Processes, Injuries in Gen- 
eral, ( omplications of Injuries and Injuries of Regions. 

Volume II. contains Diseases of Organs of Special Sense, Circulatory Sys- 
tem, Digestive Tract and Genito-Urinary Organs. 

Volume III. contains Diseases of the Respiratory Organs, Bones, Joints and 
Muscles, Diseases of the Nervous System, Gunshot Wounds, Operative and 
Minor Surgery, and Miscellaneous Subjects (including an essay on Hospitals). 

This great work, issued some years since in England, has won such universal confi- 
dence wherever the language is spoken that its republication here, in a form more 
thoroughly adapted to the wants of the American practitioner, has seemed to be a duty 
owing to the profession. To accomplish this, each article has been placed in the hands of 
a gentleman specially competent to treat its subject, and no labor has been spared to bring 
eacli one up to the foremost level of the times, and to adapt it thoroughly to the practice 
of the country. In certain cases this has rendered necessary the substitution of an entirely 
new essay for the original, as in the case of the articles on Skin Diseases, on Diseases of 
the Absorbent System, and on Anaesthetics, in the use of which American practice differs 
from that of England. The same careful and conscientious revision has been pursued 
throughout, leading to an increase of nearly one-fourth in matter, while the series of 
illustrations has been nearly trebled, and the whole is presented as a complete exponent 
of British and American Surgery, adapted to the daily needs of the working practitioner. 

In order to bring it within the reach of every member of the profession, the five vol- 
umes of the original have been compressed into three by employing a double-columned 
royal octavo page, and in this improved form it is offered at less than one-half the price of the 
original. It is printed and bound to match in every detail with Reynolds' System of Medi- 
cine. The work will be sold by subscription only, and in due time every member of the 
profession will be called upon and offered an opportunity to subscribe. 

Great credit is due to the American editor and 



The authors of the original English edition are 
men of the front rank in England, and Dr. Packard 
has been fortunate in securing as his American 
coadjutors such men as Bartholow, Hyde, Hunt, 
Conner, Stimson, Morton, Hodgen, Jewell and 
their colleagues. As a whole, the work will be 
solid and substantial, and a valuable addition to 
the library of any medical man. It is more wieldly 
and more useful than the English edition, and with 
! anion work— "Reynolds' System of Medi- 
cine*' — will well represent the present state of our 
science. One who is familiar with those two works 
will be fairly well furnished head-wise and hand- 
wise.— The Medical News, Jan. 7, 1882. 
This work is cyclopaedic in character, and every 
■ is treated in an exhaustive manner. It is 
ly designed for a reference book, which 
-.\-j; surgeon should have under hand 
in cases which require more than ordinary knowl- 



his co-laborers for revising and bringing within 
easy reach of American surgeons a work which has 
been received with such universal favor on the 
other side of the Atlantic as Holmes' System of 
Surgery. With regard to the mechanical execu- 
tion of the work, neither pains nor money seem, 
to have been spared by the publishers. — Med. and 
Surg. Reporter, Sept. 14, 1881. 

In the revision of the work for the American 
edition not only has provision been made for a 
recognition of the advances made in our knowledge 
during the ten years since its first publication,, 
but also for a presentation of the variations in 
practice which characterize American surgery and 
distinguish it from that of Great Britain. The 
work is one which we take pleasure in com- 
mending to the notice of our readers as an ency- 
clopfedia of surgical knowledge and practice.— 



-Chicago Med. Journ. and Exam., Feb. 18S2. I St. Louis Courier of Medicine, Nov. 1881 



HAMILTON, FRANK H., M. D., II. Z>., 

Surgeon to Bcllevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition,. 
thoroughly revised and much improved. In one very handsome octavo volume of about 
loot i pages, with about 375 illustrations. Shortly. 



MARSH, HOW AMD, F. R. C. S., 

Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. 
Diseases of the Joints. In one 12mo. volume. Preparing. See Series of Clinical 

_ 

PICK, T. BICKERING, F. R. C. S., 

and Lecturer on Surgery at St. George's Hospital, London. 
Fractures and Dislocations. In one 12mo. volume. Preparing. See Series- 
' inical Manuahf page 5. 



Henry C. Lea's Son & Co.'s Publications — Frac, Disloc, Ophtlinl. 23 
STIMSOX, LEWIS A., B. A., M. D., 

Professor of Pathological Anatomy at the Cnivertitv of the 07i/ of X, . ami Curator 

to Bellevue Hospital, Surgeon to the Presbyterian 11 

A Practical Treatise on Fractures. In one very handsome octavo volume of 
598 pages, with 360 beautiful illustrations, doth, $4.75 ; Leather, $5.75. 
The author gives in clear language all that the The author has given to the medical profession 

practical surgeon need know of the science of in this treatise on fractures what is likely to be- 

fractures, their etiology, symptoms, processes of come a Standard work on the subject It i> certainly 

union, and treatment, according to the latest de- not surpassed by any work written in I 

velopments. On the basis of mechanical analysis or. for that matter, any other languaj 

the author accurately and clearly explains the thor tells us in a short, < 

clinical features of fractures, and by the same manner, all that is known about his sab 

method arrives at the proper diagnosis snd rational is nothing scanty or superficial about it, ae In 

treatment. A thorough explanation of the patho- other treatises ; on the contrary, everything is thor- 

logical anatomy and a careful description of the ough The chapters on repair of fractures and their 

various methods of procedure make the book full treatment show him not only to be a profound Btu- 

of value for every practitioner. The diction is dent, but likewise a practical surgeon and pal 

simple, clear and vivid. Wherever desirable, brief gist. His mode of treatment of the different fraot- 

clinical histories are introdueted. which, being ares Is eminently sound and practical. We consider 

skillfully chosen to illustrate particular point.-, this work one of the best on fn twill 

attest the rich experience of the author. The be welcomed not onlv as a text-book, but al 

numerous beautifully-executed illustrations form the surgeon in full practice.— i\ T . 0. Medical and 

an especial attraction of the book.— Centralblatt Surgical Journal* March, 
fur Chirurgle, May 19, 1SS3. 

WELLS, J. SOELBEEG. E. B. C. K, 

Professor of Ophthalmology in King's College Hospital, London, etc. 

A Treatise ou Diseases of the Eye. Fourth American from the third London 
edition. Thoroughly revised, with copious additions, by Cha ll, M. 1'.. 81 1 

and Pathologist to the X< j w York Eye and Ear Infirmary. In one large octavo volume of 
.^22 pages, with 257 illustrations on wood, six colored plates, and selections from the Test- 
types of Jaeger and Snellen. Cloth, $5.00; leather, $6.00; half Russia, $6.50. 

The present edition appears in less than three for the nhysician to have an acquaintance with the 
years since the publication of the last American pathology and therapeutics ol I im no 

edition, and yet, from the numerous recent invi urately derive this 1 

tigations tha't have been made in this branch of knowledge than from the volume before US,— 
medicine, many changes and additions have been Mi 

required to meet the present scope of knowledge .\nvone desirous of obtaining the most 00D1- 
upon this subject. A critical examination at once p i e te work on d iglish 

shows the fidelity and tiioroughness with which language, will find in this treatise the fulfill 
the editor ha- accomplished his part of the work. of fl iat desire. 1 >r. Bui 
The illustrations throughout are good. a brief but very excellent 

tion can be recommended to all as a complete ()f foe pi logy during 

treatise on diseases of the eye, than which proba- tne ,,.,., ,,.„ years, it is n.. ■ 
bly none better exists.— Medical Record, A ;,. j n ,,i.-di- 

This magnificent work is par excellence the cine than this: certainly no medical lil 
standard work of the times on the important sub- be considered complete without it.— ' 
jects of which it treats. It is absolutely necessary col ■■ 

XETTLESHIB, EDWAEB, F. B. C. S.. 

Ophthalmic Surg, m 

The Student's Guide to Diseases of the Eye. New edition. With a chap- 
ter on the Detection of Color-Blindness, by William Thomson, M. ! >., Ophthalmol 
to the Jefferson Medical College. In one royal l2mo. volume of ilo pages, with 
illustrations I 0. 

Thi~ admirable guide bids fair to become the been received show 

favorite text-book on ophthalmic surgery with stu- ciation 1 

dents and general practitioners. It bears through- Dr. '1 homson ha* 

out the imprint of sound judgment combined with ness, on which subjeot I 

vast experience. The illustrations are numerous arc well known. With this valuable 

andweM chosen. This book, within the short com- b» 

tains a lucid exposition of the eye yet publishi 
of'tV- modern aspect of ophthalmic science.— notice of student 

juleb, iu:m:y. 1 . 1:. c. >.. 

A Handbook of Ophthalmic Science B 
volume, with many woodcut- and chromo-lithographa. I 

BBOWXi:, EDGMl 17, 

Surgeon to tht I 

How to Use the Ophthalmoscope. 
thalmoscopy, arranged for th< :| r ". v:i1 I2ma YOlnnM of IH 

■ i,u - 

LAWSON ON INJURIES TO TH1 

Effects. 8 VO., 4- »4 pp., '< 2 i 1 1 u 9. 1 

LAU1 

OPHTHALMIC SURGERY, for the OM of I'rac- 1 * ome ociaro voium .. 



24 Henry C. Lea's Son & Co.'s Publications — Otol., Dent.,Urin. Dis. 
POLITZER, ADAM, 

Hob-Royal Prof, of Aural Therap. in the Univ. of Vienna. 
A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Cassells, M. D., M. E. C. S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 



The anatomy, physiology, pathology, therapeu- 
tics and bibliography of the ear are so ably and 
thoroughly presented, that he who has carefully 
read this imposing volume can feel sure that very 
little of 'interest or value in the past or present of 
aural 3urgery has escaped him. — Am. Jour, of the 
Med. Sciences, July, 1883. 

The work itself we do not hesitate to pronounce 
the best upon the subject of aural diseases which 
has ever appeared, systematic without being too 
diffuse on obsolete subjects, and eminently prac- 
tical in every sense. The anatomical descriptions 



of each separate division of the ear are admirable, 
and profusely illustrated by woodcuts. They are 
followed immediately by the physiology of the 
section, and this again by the pathological physi- 
ology, an arrangement which serves to keep up the 
interest of the student by showing the direct ap- 
plication of what has preceded to the study of dis- 
ease. The whole work can be recommended as a 
reliable guide to the student, and an efficient aid 
to the practitioner in his treatment. — Boston Med- 
ical and Surgical Journal, June 7, 1883. 



BURNETT, CHARLES H., A. M., M. JD., 

Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
far the use of Medical Students and Practitioners. New edition. In one handsome octavo 
volume of about 700 pages, with about. 100 illustrations. Shortly. 

COLEMAN, A., L.R. C. JP., E. R. C. S., Exam. L. D. S., 

Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomeiv's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stelltvagen, M. A., M. D., 
D. J). S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 






This volume deserves to rank among the most 
important of recent contributions to dental litera- 
ture. Mr. Coleman has presented his methods of 
practice, for the most part, in a plain and concise 
manner, and the work of the American editor has 
been conscientiously performed. He has evidently 
labored tonresent his convictions of the best modes 



of practice for the instruction of those commenc- 
ing a professional career, and he has faithfully en- 
deavored to teach to others all that he has acquired 
by his own observation and experience. The book 
deserves a place in the library of every dentist. 
—Dental Cosmos, May, 1882. 



GROSS, S. D., M. !>., LL. L>., JD. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D., Professor of the Principles of 
Surgery and of Clinical Surgery in the Jefferson Medical College, Philadelphia. In one 
octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. 

F'>r reference and general information, the phy- | sual advantage of being easily comprehended by 
,i- surgeon can find no work that meets their the reasonable and practical manner in which the 
more thoroughly than this, a revised various subjects are systematized and arranged. 
edition i >f an excellent treatise. Replete with hand- — Atlanta Medical Journal, Oct., 1876. 
some illustrations and good ideas, it has the unu- 



ROBERTS, WILLIAM, M. D., 

Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. Illustrated by 
numerous engravings. In one large and handsome octavo volume. Preparing. 

MORRIS, HENRY, M. B., F. R. C. S., 

■■■' J',,.: ■.-,; Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume. Preparing. See 
qf Clinical Manuals, page 5. 

Lucas, clement^mTbT, b. s., f. r. c. s., 

\ vrgeon to Gruy's Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
rical Manuals, page 5. 

THOMPSON, SIR HENRT^~ 

rgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulae. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

BASHAM ON RENAL DISEASES : A Clinical I one 12mo. vol. of 304 pages, with 21 illustrations. 
Guide to their Diagnosis and Treatment. In | Cloth, $2.00. 



Henry 0. Lea s Sox & Co.'s Publications — Venereal, Impotence. 



BF3ISTFAI). F. J., and TAYLOR, R. W. 9 

31. 1).. LL. &., A. 31.. 31. B., 

Late Professor of Venereal Diseases Prof, of 

at the Physicians and 

Surgeons, New York; etc. 

The Pathology and Treatment of Venereal Diseases, Including the 
results of recent investigations upon the subject. Fifth edition, revised and largely re- 
written. In- Dr. Taylor. In one large and handsome octavo volume of 898 pages with 
139 illustrations, and thirteen chromo-lithographic figures, (loth. $4.75; Leather, $5.75; 
very handsome hall' Russia, $6.25. 

It is a splendid record of honest labor, wide The character of thia -tan. lard work la 
research, jus: comparison, careful scrutiny and known that it would be superfluous 
original experience, which will always be held as r< view its general or Bpecial points of excellence. 
a high credit to American medical literature. This The verdict of the profession ha- h. ■• n passed; it 
is not only the best work in the English language has been accepted as the most thorough and oom- 
unon the subjects of which it treats, but also one plete exposition of the pathology and treatment of 
which has no equal in other tongues for its clear, venereal diseases in the language. Admirable as a 
comprehensive and practical handling of its model of clear description, an exponent of sound 
theme?.— American Journal of the Jtfi . pathological doctrine, and a guide for rational and 

Jan. 1-S4. -ful treatment. It is an ornament to tl 

It is certainly the best single treatise on vene- cal literature of this country. The additions made 



real in our own, and probably the best in any Ian- to the present edition are eminently judicious, 
guage. — Boston Medical and Surgical Journal, April from the standpoint of practical utility'.—.' 
3. L8&L Outa ,<h. issi 



HZTCHIXSOX. JOXATHAX, F. R. S., F. R. ( . S.. 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12rno. volume. Preparing. v ' x 



CORXIL, V. 9 

Professor to the Faculty of Medicine of Pa spUak 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. IIknuv C. BlMES. 
M. I).. Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of 8 
in the University of Pennsylvania. In one handsome octavo volume of 46] pages, with 
84 very beautiful illustrations. Cloth. | 

The anatomical and histological characters of the the whole volume is the clinical experi< 
Uard and soft sore are admirably described. The author or the wide acquaintance of the trai 
multiform cutaneous manifestations of the disease with medical literature more evident. The anat- 
are dealt with histologically in a masterly way. a^ omy, the histology, the pathology and the clinical 
we should indeed expect'them to be, "and" the features of syphilis are represented in this work in 
accompanying illustrations are executed carefully their best, most practical and most Instructive 
and well. The various nervous lesions which are form, and no one will rise from its perusal without 
the recognized outcome of the syphilitic dyscrasia the feeling that his grasp of the Wide and Impor- 
are treated with care and consideration. Syphilitic tant subject on which it i 
epilepsy, paralysis, cerebral syphilis and locomotor surer one.— The London Practiti 
ataxia are subjects full of interest ; and nowhere in ! 



GROSS, SA3IX7FL W., A. 31., M. JD., 

Professor of the Principles of Surg' 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. Second edition, thoroughly revised, [none very hand- 
some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50. 

The author of this monograph is a man of posi- This work will derive value from the hi. 
tive convictions and vigorous style. This is fusti- tog ol 

(led by his experience and by his study, which, has bo rapidly in! lition. This is, 

gone hand in hand with his 63 a book that every physician will I 

to the various organic and functional disorders of In hi- libra) 
the male generative apparab - ad ex- and with ln< i 

ceptional opportunities for observation, and his sides the sul 
book shows that he has not i, • . of In theii 

spermatorrl ftl o fully 

a work which can be safely i The work if" I 

to both physicians and c to t,, ° 

treatment"of the disturbance 
the be«t treatise on the subject with which we ar< 
acquainted.— 7' 



CLLLFRIER, A., & BTTM8TEA />. /. ./.. >/./>.. /,/,./>.. 

Surgeon to the Ho) 

York. 

An Atlas of Venereal Diseases. Translated and edited by I 
stead, M.D. In one imperial 4to. volume < doable-columns, with 26 

containing about 1" itifully colored, many of them the si; 

bound in cloth, \ en of the plat t sent by mail, on* 

HILL ON SYPHILIS AND LO 

DISOBDERS. 
LEES I .: HILIS AND SOME TIOS >h,fl.V,. 



26 Henry C. Lea's Son & Co.'s Publications — Diseases of Skin. 



HYDE, J. NEVIJSTS, A. M., M. !>., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. In one handsome octavo volume of 570 pages, with 66 beautiful and elab- 
orate illustrations. Cloth, $4.25; leather, $5.25. 



The author has given the student and practi- 
tioner a work admirably adapted to the wants of 
each. We can heartily commend the book as a 
valuable addition to our literature and a reliable 
guide to students and practitioners in their studies 
and practice. — Am. Jowrn. of Med. Sci., July, 1883. 

Especially to he praised are the practical sug- 
gestions as' to what may be called the common- 
sense treatment of eczema. It is quite impossible 
to exaggerate the judiciousness with which the 
formula? for the external treatment of eczema are 



cian in active practice. In dealing with these 
questions the author leaves nothing to the pre- 
sumed knowledge of the reader, but enters thor- 
oughly into the most minute description, so that 
one is not only told what should be done under 
given conditions but how to do it as well. It is 
therefore in the best sense "a practical treatise." 
That it is comprehensive, a glance at the index 
will show. — Maryland Medical Journal, July 7, 1883. 
Professor Hyde has long been known as one of 
the most intelligent and enthusiastic representa- 



selected, and what is of equal importance, the full j tives of dermatology in the west. His numerous 



and clear instructions for their use. — London Medi- 
cal Timrs and Gazette, July 28, 1883. 

The work of Dr. Hyde will be awarded a high 
position. The student of medicine will find it 
peculiarly adapted to his wants. Notwithstanding 
the extent of the subject to which it is devoted, 
yet it is limited to a single and not very large vol- 
ume, without omitting a proper discussion of the 
topics. The conciseness of the volume, and the 
setting forth of only what can be held as facts will 
also make it acceptable to general practitioners. 
— Cincinnati Medical News, Feb. 1883. 

The aim of the author has been to present to his 
readers a work not only expounding the most 
modern conceptions of his subject, but presenting 



what is of standard value. He has more especially his task with painstaking fidelity and with a cred- 



devoted its pages to the treatment of disease, and 
by his detailed descriptions of therapeutic meas- 
ures has adapted them to the needs of the physi- 



contributions to the literature of this specialty 
have gained for him a favorable recognition as a 
careful, conscientious and original observer. The 
remarkable advances made in our knowledge of 
diseases of the skin, especially from the stand- 
point of pathological histology and improved 
methods of treatment, necessitate a revision of 
the older text-books at short intervals in order to 
bring them up to the standard demanded by the 
march of science. This last contribution of Dr. 
Hyde is an effort in this direction. He has at- 
tempted, as he informs us, the task of presenting 
in a condensed form the results of the latest ob- 
servation and experience. A careful examination 
of the work convinces us that he has accomplished 



itable result. — Journal of Cutaneous and Venereal 
Diseases, June, 1S83. 



FOX, T., M.D., F.R. C. P., and FOX, T. €., B.A., M.R. C.S., 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitoine of Skin Diseases. With Formulas. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $1.25. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
one which we can strongly recommend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology.— British Medical Journal, July 2, 1883. 

We cordially recommend Fox's Epitome to those 
whose time is limited and who wish a handy 



manual to lie upon the table for instant reference. 
Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented.— The Medical News, December, 1883. 



MORRIS, MALCOL3I, M. D., 

Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London. 
Skin Diseases; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor- 
bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo. 
volume of 316 pages, with illustrations. Cloth, $1.75. 

To physicians who would like to know something 
about skin diseases, so that when a patient pre- 
sents himself for relief they can make a correct 
diagnosis and prescribe a rational treatment, we 
i mend this little book of Dr. 
Morris. The affections of the skin are described 
in a terse, lucid manner, and their several charac- 
18 so plainly set forth that diagnosis will be 
easy. The treatment in each case is such as the 
experience of the rnosteminent dermatologists ad- 
iti Medical News, April, 1880. 
This is emphatically a learner's book; for we 
can safely say, that in the whole range of medical 
literature there is no book of a like scope which 



for clearness of expression and methodical ar- 
rangement is better adapted to promote a rational 
conception of dermatology — a branch confessedly 
difficult and perplexing to the beginner. — St. Louis 
Courier of Medicine, April, 1880. 

The writer has certainly given in a small compass 
a large amount of well-compiled information, and 
his little book compares favorably with any other 
which has emanated from England, while in many 

Eoints he has emancipated himself from the stub- 
ornly adhered to errors of others of his country- 
men. There is certainly excellent material in the 
book which will well repay perusal.— Boston Med 
and Surg. Jowrn., March, 1880. 



WILSON, ERASMUS, F. R. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 
In one handsome small octavo volume of 535 pages. Cloth, $3.50. 

SILLIER, THOMAS, M. D., 

Physician to the Skin Department of University College, London. 
Handbook of Skin Diseases ; for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, withfplates. Cloth, $2.25. 



Henry C.Lea's Son & Co.'s Publications— Dis. of Women. 



2? 



AX A3LEBICAX SYSTEM OE O YNMGOLOG F. 

A System of Gynaecology, in Treatises by Various Authors. In two 
handsome octavo volumes , richly illustrated. In active preparation. 

LIST OF CONTRIBUTORS. 
FORDYCE BARKER. M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D.. 



HENRY F. CAMPBELL, M. D., 

BENJAMIN F. DAWSON. M. D., 
WILLIAM GOOBELL. M. D., 
HENRY F. GARRIGUES, M. D., 
SAMUEL W. GROSS, M. D.. 
B. BUNTER, M. D., 
WILLIAM T. HOWARD, M. D.. 
A. REEVES JACKSON, M. D.. 
EDWARD W. JENKS, M. D.. 

WILLIAM II 



CHARLES CARROLL LEE, M. P., 

WILLIAM T. LUSK. M. ]).. 
MATTHEW D. M ANN. M. |... 
ROBERT B. MAURY, M. !> . 
C. D. PALMER, M. D., 

WILLI \M M. POLK. M. 1 '.. 
THADDEUS A. REAMY, M. D., 
A. D. ROCKWELL, M. P.. 

I I" H. SMITH. M. !>.. 
R. srwsiU'KY SUTTON, A. M.. M. D. 

[LLARD TIDMAS, M. D., 
CHARLES s. WARD. M. ! •.. 
M. D. 



THOMAS, T. GAILLABI), 31. JD., 

Professor of Diseases of Women m the College of Physicians and Surgeons, N. Y. 
A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of - ith 266 

illustrations. Cloth, $5.00; leather. $6.00; very handsome half Russia, raised bands 

The words which follow "fifth edition" are in vious one. As a book of reference for I 
this case no mere formal announcement. The practitioner it is unequalled.— .Boston Medical and 
alterations and additions which have been made art 
both numerous and important. The attraction [t has been enlarged and carefully revised. It in 

and the permanent character of this book lie in a condensed encycT al medi- 

the clearness and truth of the clinical descriptions cine. The style of arrangement, the ■ 

manner in which each subject 



of diseases: the fertility of the author in thera- 
peutic resources and the fulness with which the 
details of treatment are described; the definite 
character of the teaching; and last, but not least, 
the evident candor which pervades it. We would 
also particularize the fulness with which the his- 
tory of the subject is gone into, which makes the 
book additionally interesting and gives it value as 
a work of reference. — London Medical Times and 
. July 30, 1881 



I, and the 
derived from probably the 
largest clinical experience in that specialty of any 
in this country, all serve to commend it in the 
highest terms to the practitioner. — NashviU 
and Surg., Jan. 1881. 
That the previous editions of the treatise of Dr. 
Thomas were thought worthy of translation intn 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit At I 



The determination of the author to keep his has made its way into the library of ev 

book foremost in the rank of works on gynaecology rician and gynescoli tide to pract ice. 

is most gratifying. Recognizing the fact that this No small number of additions have been made to 

can only be accomplished by frequent and thor- the present edition to ni:i ad <<> re- 

ough revision, he has spared no pains to make the cent improvements in treatment— Poodle Medical 
present edition more desirable even than the pre- ' Journal, Jan. 

EJDIS, ABTJBTUB W., 31. 1)., Loud., E.B. C. P., M. B.C. S., 

trie Physician to Middlesex Hospital, I pitol. 

The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one hi 
octavo volume of 576 pages, with 148 illustrations. ( lot] 

It is a pleasure to read a book so thoroughly The greatest pains bav( 'ith the 

good as this one. The special qualities which are sections relating to 

■conspicuous are thoroughness in condition, 

: application and other details 

clear at 

d the parts of the book which deal with 
|( n l i 1 1 « 
with the differ* ntiation, one from ai 
different Kind- of abdominal tumi 
titioner will therefore find in this I 

he will 

of the i , 



whole ground, clear: • 

ttement Another marked f< 
the book is the attention y.aid to the d< 
many minor surgical operations and pro 
a°, for instance, the . application of 

leeches, and use of hot water injections. 
are among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. Tl 
warmly recommended especially to Btud< 
general practitioner-, who i. 
plete rtswni. of the whole subject - 
will find manv useful hints in its page-.- 
Surg. Journ., I ' 

BABXES, ROBERT, 31. !>.. l\ //. C. 

A Clinical Exposition of the Medical ai I 
In one handsome octavo volume, with numerous illustri 

CHAJDWICK, JAMES R., A. W., M. />• 

A Manual of the Diseases Peculiar to Women. I none L2mo.vol. / 

WEST, CHARLES, K />. 

Lectures on the Diseases of Women. wn the thii 

don edition, in one octavo volume I 



/-.. 



28 Henry C. Lea's Son & Co.'s Publications — Dis. of Women, Midwfy. 
EMMET, THOMAS ADDIS, M. D., XX. D., 

Surgeon to the Woman's Hospital, Neiv York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of about 900 pages, with about 150 illustrations. In press. 

A few notices of the previous edition are appended: 



No gynaecological treatise has appeared which 
contains an equal amount of original and useful 
matter: nor does the medical and surgical history 
of America include a book more novel and useful. 
The tabular and statistical information which it 
contains is marvellous, both in quantity and accu- 
racy, and cannot be otherwise than invaluable to 
future investigators. It is a work which demands 



ceived more attention than in America. It is, 
then, with a feeling of pleasure that we welcome a 
work on diseases of women from so eminent a 
gynaecologist as Dr. Emmet. The work is essen- 
tially clinical, and leaves a strong impress of the 
author's individuality. To criticise, with the care 
it merits, the book throughout, would demand far 
more space than is at our command. In -parting. 



linuir in \ *r^i ituiiwi .t. jl i> i^ ci » ui i\ vviiiv.il ucuirtuuo iiivjic o]j<i^d iiiau ic av \jixi \s\jllilikxla\a.. j.u ■pai niig, 

not careless reading but profound study. Its value we can say that the work teems with original 
as a contribution to gynaecology is, perhaps, i ideas, fresh and valuable methods of practice, and 
greater than that of all previous literature on the | is written in a clear and elegant style, worthy of 
subject combined. — Chicago Med. Gaz., April 5, '80. the literary reputation of the country of Longfellow 
In no country of the world has gynaecology re- 1 ana O. W. Holmes. — British Med. Jour., Feb. 21, '80. 



DUJYCAJV, J. MATTHEWS, M.D., EL. D., F. B. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

Thev are in every way worthy of their author ; | stamp of individuality that, if widely read, as they 
indeed, we look upon them as among the most | certainly deserve to be, they cannot" fail to exert a 



valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 
rule, adequately handled in the text-books ; others 
of them, while Gearing upon topics that are usually 
treated of at length in such works, yet bear such a 



wholesome restraint upon the undue eagerness 
with which many young physicians seem bent 
upon following the wild teachings which so infest 
the gynaecology of the present day. — N. Y. Medical 
Journal, March, 1880. 



GUSSEBOW, A., 

Professor of Midwifery a,'.d the Diseases of Children at the University of Berlin. 

A Practical Treatise on Uterine Tumors. Specially revised by the Author, 
and translated with notes and additions by Edmund C. Wendt, M. D., Pathologist to the 
St. Francis Hospital, N. Y., etc., and revised by Nathan Bozeman, M. D., Surgeon to the 
Woman's Hospital of the State of New York. In one handsome octavo volume, with about 
40 illustrations. Preparing. 



HODGE, HVGHL., M. D., 

Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. 
On Diseases Peculiar to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 
pages, with original illustrations. Cloth, $4.50. 



By the Same Author. 
The Principles and Practice of Obstetrics. Illustrated with large litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts In one large quarto volume of 542 double-columned pages. Strongly bound in 
cloth, $14.00. 

# * * * Specimens of the plates and letter-press will be forwarded to any address, free by 
mail, on receipt of six cents in postage stamps. 



TABJSTIEB, 8., and CHAJSTTBEUIL, G. 

A Treatise on the Art of Obstetrics. Translated from the French. In 
two large octavo volumes, richly illustrated. 



BAMSBOTHAM, FBANCIS H., M. D. 

The Principles and Practice of Obstetric Medicine and Surgery; 

In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., 
in the Jefferson Medical College of Philadelphia, In one large and handsome imperial 
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 

ASHWELL'S PRACTICAL TREATISE ON THE AND OTHER DISEASES PECULIAR TO WO- 
DISEASES PECULIAR TO WOMEN. Third MEN. In one 8vo. vol. of 464 pages. Cloth, $2.50. 

^1nn an Tn r ^L e he th i rd an An reV ^? e £ L £ n C n° n I MEIGS ON THE NATURE, SIGNS AND TREAT- 
edition. In one 8vo. vol., pp. 520. Cloth, $3.50. I MENT 0F CHILDBED FEVER. In one 8vo. 
CHURCHILL ON THE PUERPERAL FEVER volume of 346 pages. Cloth, $2.00. 



Henry C. Lea's Son & CJo.'s Publications— Midwifery. 29 

FLAYFAIR. W. s.. M. I)., F. JR. €. P., 

Professor of Obstetric Medicine in Kind's College, Lon&i 

A Treatise ou the Science and Practice of Midwifery. Third American 
edition, revised by the Author. Edited, with additions, by Robert I*. BLajlrib. M. D. 
In one handsome octavo volume of 659 pages, with L83 illustrations, Cloth, $4 : Leather, 

$5; half Russia. |5.50. 

The medical profession has now the opportunity all details not necessary for a lull understanding 

of adding to their stock of standard medical work's of the subject arc omittecL— Cincinnati 

one of trie best volumes on midwifery ever pub- News, Jan., 1880. 

rished. The subject is taken up with a master u certainly i> an admirable exposition of the 

hand. The part devoted to labor m all its various science and practice of midwifery. Of course the 

presentations, the management and results. i> ad- additions male by the American editor, Dr. K. P. 

mirably arranged, and the views entertained will Harris, who never utters an idle word, and whose 

be found essentially modern, and the opinions ex- studious researches in boo irtmenta 

trustworthy. The work abounds with f obstetric are so well known to the pr< 

plates, illustrating various obstetrical positions; are of treat value.— 

they are admirably wrought, and afford great April. 1880. 

assistance to the student.— 3". 0. Medical sad .<■>■•■ -The third edition— so soon following the - 

gica! Journal, March, 1880. shows that the good qualities of the book have been 

If inquired of by a medical student what work recognized by the profession. The second Ameri- 
ca obstetrics we should recommend for him, par can has been exhausted before the second English 
excellence, we would undoubtedly advise him to edition, and this i- 

choose Playfair's. It is of convenient size, but and r. tuthor for thfe country ; afoot 

what is of chief importance, its treatment of the which ought to be satisfaetorv as to the | 

various subjects is concise and plain. While the here being furnished with the latest work upon all 

discussions and descriptions are sufficiently elabo- subjects pertaining to obstetrics.— Am. J 

rate to render a very intelligible idea of them, vet Med. Sciences, April, 1880. 



KIXG, A. F. A., M. I)., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbia,! ' 
situ, Washington, D. C, and in the 7 rmont, etc. 

A Manual of Obstetrics. New edition. In one very handsome 12mo. volume 
of 331 pages, with 59 illustrations. Cloth, $2.00. Just ready. 

In a series of short paragraphs and by a con- that it will be in great demand by them, so suited 
denied style of composition, the writer hi - 

sented a great deal of what it i- well that every carried, yet it contains all of the main points In 

obstetrician should know and be ready to practice obstetrics sufficiently elaborated to give a full and 

or prescribe. The fact that the demand for the correct idea of them. The general pn 

volume has been such as to exhaust the first will also find it very useful for reference, for the 

edition in a little over a year and a half speaks purpose of refreshing the mind. We C 

well for its popularity.— A meriean Journal of tht dently assert that it will be found to be I 

. 1884. class 'text-book upon obstetrics that I 

This little work upon obstetrics will be highly issued from the pn - 

valued by medical students. We feel quite *ure Mam 



PARVIX, THEOFHILLS, M. I)., LL. &., 

Profe* 

A Treatise on Midwifery. In one very handsome octavo volume of about 550 

pages, with numerous illustrations. I 



BARXES, ROBERT, M. U., and FAXCOURT. M. />., 

Phys. to the Qt 0&8f< ' 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section <>n Embryology contributed l>y 
Prof. Milnea Mar-hall. In two handsome octavo volumes, profusely illustrated. / 

barxes, eax( <>riri\ />/. />., 

•'"/, London. 

A Manual of Midwifery for Midwives and Medical Students. I 
royal 12mo. volume of 197 pages, with 50 ill 

PARRY, JOJfX S., M. JD. 9 

■ ician to the I 

Extra - Uterine Pregnancy: In Clinical Hi 

Treatment. In one han 

TAXXER, THOMAS HA UK FS. M. I>. 

On the Signs and Diseases of Pregnancy. Fin* American fr. 
English edition. In one handsome octavo volume 
Id woodcuts 

WIXCKEL, F. 

A Complete Treatise on the Pathology and Trc 
For Students and Practi-: . with the consent ol the Author, n 

second German edition, by Jambs Bead Ch J 

pages. Cloth, $4. 



oil Henry C. Lea's Son & Co.'s Publications — Midwfy., Dis. Gliildn. 



LEISH3IAJST, WILLIAM, 31. I)., 

U Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia 'Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50; leather, 
(5.50 : very handsome half Russia, raised bands, $6.00. 



The author is broad in his teachings, and dis- 
cusses briefly the comparative anatomy of the. pel- 
vis and the mobility of the pelvic articulations. 
The second chapter is devoted especially to 
the study of the pelvis, while in the third the 
female "organs of generation are introduced. 
The structure and development of the ovum are 
admirablv described. Then follow chapters upon 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the work are 
plain'and pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 

We gladly welcome the new edition of this ex- 
cellent text-book of midwifery. The former edi- 
tions have been most favorably received by the 
profession on both sides of the Atlantic. In the 



preparation of the present edition the author has 
made such alterations as the progress of obstetri- 
cal science seems to require, and we cannot but 
admire the ability with which the task has been 
performed. We consider it an admirable text- 
book for students during their attendance upon 
lectures, and have great pleasure in recommend- 
ing it. As an exponent of the midwifery of the 
present day it has no superior in the English lan- 
guage. — Canada Lancet, Jan. 1880. 

To the American student the work before us 
must prove admirably adapted. Complete in all its 
parts, essentially modern in its teachings, and with 
demonstrations noted for clearness and precision, 
it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 
popular and is cordially recommended. — N. O. 
Med. and Surg. Jovrn., March, 1880. 



SUITS, J. LEWIS, M. D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. 

A Complete Practical Treatise on the Diseases of Children. Fifth 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, 
with illustrations. Cloth, S4.50 ; leather, $5.50 ; very handsome half Eussia, raised bands, $6. 

which we venture to say will be a favorable one. — 



II 



This is one of the best books on the subject with 
which we have met and one that has given us 
satisfaction on every occasion on which we have 
consulted it, either as to diagnosis or treatment. 
It is now in its fifth edition and in its present form 
is a very adequate representation of the subject it 
treats of as at present understood. The important 
subject of infant hygiene is fully dealt with in the 
earlv portion of the hook. The great bulk of the 
work is appropriate^ devoted to the diseases of 
infancy and childhood. We would recommend 
any one in need of information on the subject to j 
procure the work and form his own opinion on it, j 



Dublin Journal of Medical Science, March, 1883. 

There is no book published on the subjects of 
which this one treats that is its equal in value to 
the physician. While he has said just enough to 
impart the information desired by general practi- 
tioners on such questions as etiology, pathology, 
prognosis, etc., he has devoted more attention to 
the diagnosis and treatment of the ailments which 
he so accurately describes ; and such information 
is exactly what is wanted by the vast majority of 
" family physicians."— Va. Med. Monthly, Feb. 1882. 



KLATIJSTG, JOHNM., M. D., 

Lecturer on the Diseases of Children at the University of Pennsylvania, etc. 

The Mother's Guide in the Management and Feeding of Infants. In 

one handsome 12mo. volume of 118 pages. Cloth, $1.00. 



Works like this one will aid the physician im- 
mensely, for it saves the time he is constantly giv- 
ing his patients in instructing them on the sub- 
jects here dwelt upon so thoroughly and prac- 
tically. Dr. Keating has written a practical book, 
has carefully avoided unnecessary repetition, and 
successfully instructed the mother in such details 
of the treatment of her child as devolve upon her. 
He has studiously omitted giving prescriptions, 



the employment of a wet-nurse, about the proper 
food for a nursing mother, about the tonic effects 
of a bath, about the perambulator versus the nurses' 
arms, and on many other subjects concerning 
which the critic might say, "surely this is obvi- 
ous," but which experience teaches us are exactly 
the things needed to be insisted upon, with the rich 
as well as the poor. — London Lancet, January, 28 1882. 
A book small in size, written in pleasant style, in 



and instructs the mother when to call upon the j language which can be readily understood by any 
doctor, as his duties are totally distinct from hers, j mother, and eminently practical and safe; in fact 
-American Journal of Obstetrics, October, 1S81. | a book for which we have been waiting a long 



Dr. Keating lias kept clear of the common fault 
of works of this sort, viz., mixing the duties of 
the mother with those proper to the doctor. There 
Is the ring of common sense in the remarks about 



time, and which we can most heartily recommend 
to mothers as the book on this subject. — New York 
Medical Journal and Obstetrical Review, Feb. 1882. 



OWJEJST, JEJD3IUJSm, M. B., F. It. C. S., 

on to the Children's Hospital, Great Ormorui St , London. 
Surgical Diseases of Children. In one 12mo. volume. Preparing. See Series 
of Clinical Momuals, page 5. 

WEST, cjscakles^lIlx, 

Physician to the Hospital for Sick Children, London, etc. 

Lectures on the Diseases of Infancy and Childhood. Fifth American 
from 6th English edition. In one octavo volume of 686 pages. Cloth, $4.50; leather, $5.50. 

By the Same Author. 
On Some Disorders of the Nervous System in Childhood, in one small 
12mo. volume of 127 pages. Cloth, $1.00. 



CONDIE'S PRACTICAL TREATISE ON THE! vised and augmented. In one octavo volume of 
DISEASES OF CHILDREN. Sixth edition, re- | 779 pages. Cloth, S5.25 ; leather, $6.25. 



Henri- C. Lea's Son & Co.'s Publications-— Med. Juris., BflseeL 31 
TIDY. CWA RT<1?S MEYMOTT, M. />.. F. C. SL, 

Professor of Chemistry and of Forensic Medicine a •!, etc. 

Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide. Asphyxia, 
Drowning. Hanging, Strangulation. Suffocation. Making a very handsome imperial oc- 
tavo volume -. Cloth, $6.00 ; leathei 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth. |6.00; leather, - 

He whose inclinations or necessities load him to The fact that the very numerous illustra' 

assume the functions of a medical jurist wants a are drawn from many sources, and arc not limited, 

book encyclopaedic in character, in which he may a- in Casper's Handbook, to the author's 

be reasonably sure of finding medico-legal topics perience, and the additional foot that they are 

i wih judicial fairness, with sufficient brought down to a very recent date, givi 

completeness, and with due attention to the most for purposes of reference, b very obvious 
recent advances in medical science. Mr. Tidy's 
work bids fair to meet this need satisfactorily. 



TAYLOR. ALFRED S., M. L)., 

Lecturer on Medical Jurisprudence and Chtmistni in Gv ulon. 

A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited byJoHB J. Ki.i; i:. M. I ».. !' 
of Medical Jurisprudence and Toxicology in the University of Pennsylvania, In one 
tavo volume of 937 pages, with 70 illustrations, cloth, $6.00; Leather, $6.00; half 
Russia, raised hand-. 

The American editions of this standard manual only have to seek for laudatory terms.— 
have for a long time laid claim to the attention of Journal of tht ces, Jan. 1881. 
the profession in this country: and the eighth This celebrated work has been the standard au- 
comes before us as embodying the latest thoughts thority in its department for thirty-seven years, 
and emendations of Dr. Taylor upon the subject both in England and America, in both th< 
Id which he devoted his life with an assiduity and sions which i( litis improba 
succes- which made him facile princeps among j t will be superseded in mat work is 
mterson medical jurisprudence. Both simplyindis] - : physician, and nearly 
the auth ok have made a mark every liberally-educated la 
deep to be affected hy criticism, whether it be heartily commend the present edition to both pro- 
censure or praise. In this case, however, we should fessions.— Albany Law Journal, March 28, 1881. 

By the Same Author. 

The Principles and Practice of Medical Jurisprudence. Third edition. 

In two handsome octavo volumes, containing 14K) i . . - illustrations. 

leather, $12. JusL 

Taylor's Treatise at the hands of I - Including within its purview, 

has undergone a diminution of bulk with an in- 

This edition only asserts with Bion of m< o 
stronger reason the allowed claims of the late Dr. will ever remain an invalu 
Taylors work to the first position among English — 2V< 

By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. ' 
American, from the third and revised English edition. In one 
pages. Cloth, $5.50; leather, | 

1>HP¥EH, AUGUSTUS J.. M. &, M. B., F. /.\ C. S., 

Forensic Medicine. In i 

LEA, HENRY C. 

Superstition and Force : Essays on The Wager of Law. The Wa 
Battle, The Ordeal and Torture. Third In ona 

hand 

doable work is in reality a h 
Dization a 4 - interpreted by I 



] primitive barbarity 
enment. There is not a chapter in the work that 



' 



By the Same Author. 
Studies in Church History. The Rise of tho Tempor. 
efit of Clergy— Excommunication, 
octavo volume of 6 

Theaut 
up every topic allied with t. 
traces it out t 
of knowledge a 
compel admiration. 1 
compressed into the book i- 
other single volume la the develo] 



Amert 

► Ashhuist's Suruory .... 
^Lshweli on Diseases of Women 
Attfleld'8 Chemistry .... 
liariow's Practice of Medicine 
Barnes' Midwifery .... 

,11 Diseases of Women 
Harms' svsti m ol' Obstetric Medicine 

n\v i.ii Electricity 
Ra^ham on Renal Diseases . 

• mparative Physiology and Anatomy 
\ s Operative Surgery 

Bellamy's Sur-ieal Anatomy 
Blandford on Insanity 

i's Chemistry .... 
Bowman's Practical Chemistry 

■\ e's Practice of Medicine . 
Broadbi nt on the 1'uise 
Browne on the Ophthalmoscope . 
Browne on the Throat 

Bruce's Materia Medica and Therapeutics 
Brunton'a Materia Medica and Therapeutics 
Brj ani on the Breast .... 
•Bryant's Practice of Surgery 
•Bumstead on Venereal Diseases . 
•Burnett on the Ear .... 
Butlin on the Tongue .... 
Carpenter on the Use and Abuse of Alcohol 

enter's Human Physiology . 
Carter on the Eye .... 
Century of American Medicine 
Chadwick on Diseases of Women . 
Chambers on Diet and Regimen 
Charles' Phvsiological and Pathological Chem. 
Churchill on Puerperal Fever 
Clarke and Lockwood's Dissectors' Manual 

'- ouantitative Analysis 
Cleland's Dissector .... 
Clouston on Insanity .... 
Clowes' Practical Chemistrj' 

Pathology .... 

on the Throat .... 

Coleman's Dental Surgery 

oil Diseases of Children 

^logical Histology 
Coruil on Syphilis .... 

Culleriei's Atlas of Venereal Diseases 
Curnow's Medical Anatomy 
Dalton on the Circulation 
•Dalton's Human Physiology 
Dalton s Topographical Anatomy of the Brain 
Davis' Clinical Lectures ... 
Draper's Medical Physics . 
Drum's Modern Surgery ... 
Duncan on Diseases of Women 
•Dunglison's Medical Dictionary . 

hiseases of Women ... 
nations of Anatomy 
•Emmet's Gynaecology 
•Erichsen's .System of Surgery 

■ii s Early Aid in Injuries and Accid'ts 
Farquharson'8 Therapeutics and Mat. Med. 
Fenwick's Medical Diagnosis 
Finlayson's Clinical Diagnosis 
Flint on Auscultation and Percussion 
Flint on Phthisis .... 

Flint on Physical Exploration of the Lungs 
Flint on Respiratory Organs 

;: the Heart .... 
•Flint's Clinical Medicine 
Flint's Kssavs . 
•Flint's Practice of Medicine 

of C. s. on Custody of Insane 

- Physiology . . 

•Fothergilra Handbook of Treatment 
Elementary Chemistry . 
Dis< ases of the skin . 
Frankland and Japp's Inorganic Chemistry 
Poller on the Lnngs and Air Passages . 
Galloway's Analysis .... 
surgery 

■ iy 
Pathological Histology, by Leidy 

I Diagnosis . 

■ 1 1 1 1 v . 
caJ Chemistry . 

Pathology and Morbid Anatomy 
Griffith's Universal Formulary 

:. 1 -.Mi. n Podies in Air-Passages 
nd Sterility . 
ans 

m of Surgery . 

• v .,!, Uterine Tumors 
hon on the Abdomen 
ton on Fracture- and Dislocations 

Hamilton on Nervous Diseases 

Anatomy and Physiology . 
i ne's Conspectus of the Med. Sciences 
ils of Medicine 
Hermann's Experimental Pharmacology 
Hill on Syphilis ..... 
Hlllier's Handbook of Skin Diseases 
Hoblyn's Medical Dictionary 

Books marked * are j 



Undue on Women .... 

I lodge's Obstetrics .... 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

^Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever .... 

Hutchinson on Syphilis 

Hyde on the Diseases of the Skin . 

Jones (C. Handheld) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

Keating on Infants .... 

Khm's Manual of Obstetrics . 

Klein's Histology .... 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis ..... 

Lehmann's Chemical Physiology . 

:i: Leishman's Midwifery 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maisch's Organic Materia Medica . 

Marsh on the Joints .... 

Medical News ..... 

Meigs on Childbed Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Mitchell's Nervous Diseases'of Women . 

Morris on Diseases of the Kidneys 

Morris on Skin Diseases . 

Neill and Smith's Compendium of Med. Sci. 

Nettleship on Diseases of the Eye . 

Owen on Diseases of Children 

•Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery .... 

Pavy on Digestion and its Disorders 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery . 

Playfair on Nerve Prostration and Hysteria 

•Playfair's Midwifery .... 

Politzer on the Ear and its Diseases 

Power's Human Physiology . 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

•Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Principles and Practice of Surgery 

Robertson's Physiological Physics 

Rodwell's Dictionary of Science 

Sargent's Minor and Military Surgery . 

Savage on Insanity, including Hysteria . 

Schafer's Histology .... 

Schreiber on Massage .... 

Seiler on the Throat, Nose and Naso-Pharynx 

Series of Clinical Manuals 

Simon's Manual of Chemistry 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (H. H.) and Horner's Anatomical Atlas 

•Smith (J. Lewis) on Children 

*Still<5 & Maisch's National Dispensatory 

*Still<?'s Therapeutics and Materia Medica 

Stimson on Fractures .... 

Stimson's Operative Surgery 

Stokes on Fever ..... 

Students' Series of Manuals . 

Sturges' Clinical Medicine . 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine 

Tarnier and Chantreuil's Obstetrics 

Taylor on Poisons .... 

•Taylor's Medical Jurisprudence . 

Taylor's Priii. and Prac. of Med. Jurisprudence 

■•■•Ti i' mas on Diseases of Women . 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine .... 

Todd on Acute Diseases 

Treves' Applied Anatomy . 

Treves on Intestinal Obstruction . 

Tuke on the Influence of Mind on the Body 

Walshe on the Heart .... 

Watson's Practice of Physic . 

Watts' Physical and Inorganic Chemistry 

*Wells on the Eye .... 

West on Diseases of Childhood 

West on Diseases of Women 

Wesi on Nervous Disorders in Childhood 

Williams on Consumption . 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . 

Winckel on Pathol, and Treatment of Childbed 

Wdhler's Organic Chemistry 

Woodbury's Practice of Medicine . 
I Woodhead's Practical Pathology . 
so bound in half Eussia. 



HENRY C. LEA'S SON & CO., Philadelphia. 



